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SOGI Information Critical for Effective Medical Billing

by | Jan 2, 2015 | Blog, Medical Billing

Medical BillingEfforts are already in progress to incorporate sexual orientation and gender identity (SOGI) information into EMR and insurance billing system. This is the only way recommended by the Institute of Medicine (IOM) to eliminate LGBT (Lesbian, gay, bisexual, and transgender) invisibility in healthcare and measure quality and progress at ending orientation and gender identity based disparities. Clinicians can ensure better care for LGBT people by extracting this information from EMR. For example, transgender women require regular prostate exams and EMR will alert clinicians about this if SOGI information has already been provided. This information is critical when billing for services provided as more people are enrolled in health insurance after Obamacare implementation.

The Affordable Care Act (ACA) ensures the following provisions for LGBT people:

  • The Act prohibits sexual orientation and gender identity based discrimination by Marketplaces, Navigators and other consumer assisters, and qualified health plans. Plans may not refuse coverage or charge higher premiums on the basis of being a transgender.
  • For coverage that starts on January 1, 2015, all Marketplace plans that provide spousal or family coverage must offer it to same-sex spouses.
  • A number of LGBT people will be newly eligible for Medicaid or for Marketplace subsidies.

As more people are being enrolled into health insurance or Medicaid billing, healthcare providers will see a proportionate increase in the medical billing tasks in their offices. The appropriate billing codes must be reported on the medical claims that clearly reflect the services provided. They should also reflect the needs of patients whose gender identity may not be congruent with their sex assigned at birth. For example, hormone therapy must be covered as essential for people with gender dysphoria. Providers should use the correct diagnostic code to indicate gender dysphoria in order to ensure that insurers provide payment for hormone therapy. As per an article published in the LGBT Health Journal, LGBT and HIV groups recommended that the national coordinator request the National Library of Medicine to develop new codes to reflect SO/GI data in order to facilitate effective as well as accurate collection of SO/GI data.

In short, tracking sexual orientation and gender identity information will help providers to submit medical claims properly and improve their revenue. However, decision support in EMRs related to sexual orientation and gender identity will take time, continued education and effective collaboration. In the meantime, providers should consider the sexual orientation and gender identity information when billing for prostate exams, pap tests and other relevant services.

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