65th birthday, appeal process, April deadline, bureaucracy, dentures, Derma-Lase, Dr, Dr. Carolyn Wolf-Gould, Dr. Sherman Leis, extensions, female swimsuit, full plate, Gender Reassignment Surgery, genital hair removal, GRS, health insurance, income tax preparation, Medicaid, Medicare, mouth infection, New York State, New York State of Health, NYU Plastic Surgery, oral surgery, Rachel Bluebond-Langner, Ramapo College, soft diet, tax clients, tax season, tooth problems, Transgender, victory, winning appeal
The Battles and the Progress Continues
The early winter months of 2017 brought the usual New York area snow and the onset of tax season. Snow also postponed my first appointment with Joy Vanderberg for hair removal on March 14. We were able to reschedule it for two days later. Spring was just around the corner and snow days would soon be over.
My first visit with Joy also brought an excellent report. She told me that I had much less genital hair than the other trans patients she had worked on. She also told me that I had very little gray hair in that area. I couldn’t have asked for better news.
Even so, she wanted to wait until my second visit before she gave me a time frame for how long it would take to clear me of my genital hair (excluding those sparse gray hairs that laser won’t touch). And that delay, due to no fault on Joy’s part, led to another battle.
My second session with Joy was on March 27. Based on my body’s reaction to the first session, she estimated that I could be cleared in 6 months, which would take me to sometime in August. By this time, the wait list for Dr. Leis took us into September at the earliest. Carole Sherman in Dr. Leis’s office tried for a date in September but it fell through. So the earliest date we could come up with was October 5. That wasn’t ideal for me as the recovery period would include and go past the due date for returns on extension. But I accepted the date and would just have to make it work with my clients. (I did, by the skin of my teeth.)
The scheduling wouldn’t prove to be that simple. As we were in the process of finalizing the surgery date, Dr. Leis’s office was contacted. Until this time, New York State was allowing Medicaid payments to be ported outside of the state for GRS because there were no qualified surgeons in New York State doing this surgery who also accepted Medicaid. That situation had now changed. Dr. Leis was told that he had received his last approval from New York Medicaid for a New York patient’s surgery.
Had I not had the bureaucratic gremlins’ snafu delayed approval for my consult; had not the troll delayed the start of my hair removal by at least three weeks; we would have put through a request for my surgery well in advance of the change in status between Dr. Leis and New York State. Instead, we had just missed the cutoff.
Carole told me that she would submit a request for my surgery (and a pre-surgery visit with Dr. Leis on September 13) anyway, knowing it would be denied. Then it would be up to me to appeal while she would work with my caseworker to see if an exception in my case could be pushed through. As soon as the denial was received by me, I was told that I needed to respond immediately.
There was one big problem. The denial came through promptly (amazing how the insurance carrier can move fast with denials but not approvals), right at my busiest time of tax season: the first two weeks of April. And this was already shaping up as my worst tax season in my entire 29 years as a professional tax preparer. New York had put through a requirement for taxpayers to include their driver’s license info on their tax returns (including an obscure document number that could be in different places depending upon when the license was issued, and was nearly invisible to the naked eye for the older licenses). Despite me telling my clients this info in my year end tax letter, not one New York client brought me this information. I had to put about a half dozen last minute New York clients on extension just for this reason alone. In addition, I had a number of clients in California who work for a major Internet company who had a variety of unusual tax situations that added a lot of extra hours to my prep time. I was also doing my best to maintain my commitment to a mentoring program for freshmen at a local high school.
And I had to spend time straightening up as best I could because my building management company had picked April 13 as the date for their new pest control company to inspect the apartments. This was another thing that couldn’t have come at a worst time. My life gets pretty basic at this time of year. Dishes and garbage (mainly recycling and items to shred) pile up. As many meals as possible are either sandwiches, pre-packaged meals or take out.
The bottom line is this: my clients come first, and especially at this time of year. If I think that a client wastes my time by habitually coming in late without good reason, I have been known to fire a client. But for the most part I love my clients, especially ones who have been with me for years. So when one of my dearest octogenarian (and snowbird) clients calls me in early April to tell me that she broke her shoulder and was going to have surgery and didn’t know when she could see me, how could I get mad at her or deny her to meet with me for the first time on the morning of the day that taxes were due?
I worked nearly non-stop on April 18th to complete returns or file extensions. Usually I file 10-12 extensions per year. This year I filed 26. There were 18 returns that I didn’t even start to work on until the due date. Usually I work like crazy about three to five days before the due date so that by the due date, I only have one or two stragglers to finish. I couldn’t get close to that this year. I filed the last extension (my octogenarian snowbird) with 41 minutes to spare. I had something to eat and watched an episode of Bonanza online to decompress. And then I got a few hours of sleep before waking up in time to be part of a transgender panel to speak to a class at Ramapo College.
Even then, I had some tax duties to complete: specifically my payroll client and Canadian client who have returns due at the end of the month. But somewhere during the end of April, I could finally start to work on the appeal.
Ah, but if it was only that simple. Three appeal processes were offered. So the first thing I needed was guidance on which one I should use. I ruled out one, but what of the other two? While waiting for the guidance, using my vast prior experience with bureaucratic language, I deciphered that it seemed best if my surgeon’s office filed the one appeal (which they did), while I went to work on the other process.
In my so-called spare time, I also had to deal with a problem caused by either the previous building manager for my co-op apartment building or the attorney they used. When my name was changed, it took me two years to get the name changed on my stock certificate for ownership in the co-op that entitles me to live in my apartment. When that was finally accomplished, I was told that they would contact my local town so I would not lose the school tax credit to which I was entitled. Someone dropped that ball and as of January, I was paying more in monthly maintenance because the tax credit was gone. To my local town, it looked like I had recently bought my apartment and had to apply all over again. (As of the date of this writing, I have gotten my 2017 credit, but not my 2016 credit, which I soon have to follow up on.)
The other problem I had to deal with was more painful. I was starting to have problems with my teeth. Years ago, I had a post and crown put in. That fell out, and other teeth were starting to break. I’ll mention more about this in a future post, but this was one more major item to deal with. I was getting a full plate and then some. And there was a deadline on filing the appeal.
It also needs to be mentioned that I wasn’t just denied my surgery with Dr. Leis. They did assign me to another surgeon: Dr. Rachel Bluebond-Langner at New York Langone Health/NYU Plastic Surgery Associates. So it behooved me to check out what her procedures would be. But I could get precious little over the phone and even though I have a good friend who was scheduled to have breast augmentation with her in early May and offered to find out information for me, I was running out of time for my appeal. Besides, I was able to find out the most important piece of information. This surgeon’s waiting list was already so long, with the earliest I could schedule a consult, the earliest I could have the surgery would be late spring or early summer of 2018. It was bad enough that this was just one more delay after so many delays. I would turn 65 before then. (In fact, I was barely getting in under the wire with that important date with Dr. Leis.) This would mean starting all over with new insurance, assuming that Dr. Bluebond-Langner and NYU accepted Medicare for GRS (not many places do). This was a major game changer. And I had other concerns as well, especially since I had so many unanswered questions.
So I gave high priority to my appeal, making sure that my two clients were taken care of by their respective deadlines (they were). Except for the three part harmony, I detailed all the delays caused by my insurance carrier’s representatives in a way that rivaled Alice’s Restaurant. I noted that I had already established a relationship with Dr. Leis and was in the process of finalizing a surgery date when NY State’s edict came down. I noted ways in which the surgery process in NY was inferior service to what Dr. Leis offered, at least for me.
On April 29, I mailed out the appeal and sent copies via e-mail to Carole Sherman, my insurance carrier caseworker and Dr. Carolyn Wolf-Gould. It was Dr. Carolyn who proved to be key to the way the process worked out. And at some point as tax season was winding up, she encouraged me with the information that another patient in a similar situation and with Dr. Leis as surgeon had appealed and won. She also suggested I get legal assistance, but I had already started working on my appeal at that point. I trusted in my ability to deal with bureaucrats and didn’t need another delay to make contact and go over my case with the people she recommended (5 hours away from me up in Rochester).
On May 4, my insurance carrier signed for receipt of my appeal and I received the card in the mail indicating that on May 8. I let my caseworker, Carole Sherman and Dr. Carolyn know so that they could take any further action on my behalf.
In response to sharing this news, I received the following from Dr. Carolyn on May 17:
I spoke to the chief medical officer yesterday about your case. He agreed to look into your troubles. I have been having a lot of trouble wth [this particular insurance carrier] lately, and got lawyers from Legal Aid involved behind the scenes. I believe this is why your case was appealed. I asked him to look specifically at yours and one other yesterday and both went through this morning.
So much for my writing skills. Well, I will at least take credit for choosing the right doctor! It helps to know people in positions of influence in situations like this. And this is why I always searched for people who were knowledgeable about transgender issues when it came to anything related, medical or counseling. I appreciate those who pioneered and had to, in a sense, train the people who took care of them. Dr. Carolyn and Dr. Leis didn’t learn how to treat transgender patients in medical school (and there is still too little training in that area). It took a determined transgender patient in both cases to get them started on the path they now embrace.
In a later note, Dr. Carolyn was gracious enough to share some of the credit with me:
You are very welcome, Lois. It’s people like you who make my job such a joy. I’m very pleased that both these cases went through today and also encouraged that [this particular insurance carrier] has now updated their policies.
This wouldn’t have happened if you hadn’t made a stink. You have changed things for the patients who will come after you. This makes my job easier in the future. If not for your hard work on your appeal, this huge change in the system wouldn’t have happened. If you hadn’t filed all the paperwork, there would have been nothing to review and nothing for me to point at during my phone call yesterday.
It takes a team.
But perhaps there is some sort of conservation of insurance problems, just like there is conservation of mass and energy. As of this writing, I have one relatively minor insurance situation unresolved, reimbursement for my travel and lodging related to the gender surgery, at least issues regarding my gender surgery. But new issues cropped up regarding my teeth and my turning 65.
I will not spend a lot of time on these issues, as they are not directly related to my blog. But they have complicated my life at a time when I need to recover from my GRS and need no complications.
Basically what happened is that I went to the dentist about my teeth at the end of April. He didn’t like what he saw on my x-rays and had a more detailed scan done. From that, he submitted a plan of extensive root canals and crowns. Some dentist sitting behind a desk decided his plan was not warranted, because the teeth and gums were not in good enough condition. So we went the opposite direction: pull all the teeth and put in dentures. The dental desk jockey turned that down as well because six teeth could be saved. They did cover the extractions of most of the teeth, but not the dentures and not the extractions of six teeth. Despite dental coverage, it cost me $4500 dollars, most of which I have charged, but that eventually has to be paid off.
Then there was the matter of the timing of the extractions. I am in the process of switching from Medicaid to Medicare plus a Medicare supplemental plan. Oral surgery is part of my Medicaid coverage, but the oral surgeons in my area are only available a few days a month when they take Medicaid. Therefore, they tend to be booked well in advance.
This created a second problem: when did I switch from Medicaid to Medicare? I assumed it would be on my 65th birthday, in mid-November. Wrong! Medicare started on the first day of November for me. So Medicaid would end on the last day of October, right? That’s what I was told by the Department of Social Services in my county, New York State of Health (the Obamacare marketplace in New York through which I had been applying for health insurance coverage) and my insurance carrier.
They were all wrong. While I was in Pennsylvania recovering from my GRS, I received a notice that my Medicaid coverage will be terminating on the last day of November. Had I received the correct information; had I known that before I left for Bala Cynwyd, I could have made different arrangements with my dentist and the oral surgeon. I could have either postponed the surgery until November, or had the back teeth pulled in October and the front ones pulled in November and started with the dentures after the rest of the teeth were pulled. The latter way would have been the preferred way as it allows the gums to heal better.
Instead, I came home from GRS recuperation on October 19, two weeks after my GRS surgery, and on October 20 I had all my teeth pulled. By the 27th, I couldn’t wear my dentures, the pain was so great. A terrible post-operative infection devastated my gums, leaving large areas of exposed bone. I had to take a week’s worth of a strong antibiotic plus do a 50% hydrogen peroxide rinse to combat the problem. While the gums are growing back over the bones, I still have significant areas of exposed bone. I will be without teeth until at least December 6 and on a soft food diet for all this time.
Oh well, at least my current diet might help me get in shape for my first swimsuit season without any fear of a bulge. Still, while there is no definitive proof possible, my recovery from both surgeries was compromised because of the ignorance of bureaucrats.
My people are destroyed for lack of knowledge: – Hosea 4:6a