Transgender patients’ gender often is indicated incorrectly at registration. This results in inappropriate claims denials for patient access and difficulty obtaining needed care. Patient access leaders can:

  • instruct registrars to ask patients how they want their gender listed, without making assumptions;
  • work with vendors to change systems to accept multiple gender codes;
  • ensure clinical systems allow for gender identification other than the assigned sex at birth.

If gender isn’t indicated correctly at registration, it can result in inappropriate claims denials, hours of phone calls trying to correct the problem, and incredible frustration on the part of the patient. Yet, most patient access departments have no way to address these problems involving transgender patients.

“Gender identity is an evolving area that affects registration, intake, and subsequent care,” says Kathleen Shostek, RN, ARM, CPHRM, vice president in the healthcare risk management and patient safety division of Sedgwick, a third-party administrator for professional liability claims.

Most registration systems give only two choices: male or female.

“But we have transgender individuals and those who do not identify with one or the other,” Shostek explains. This can cause claim denials, as with a patient whose birth gender is male and requires a prostate-specific antigen test, but now identifies as female.

Melissa A. Salyer, CRCR, director of patient access at Chesapeake (VA) Regional Healthcare, says that in her 15 years of experience, “registering and billing procedures for transgender patients has always been a challenge and concern in the hospital community.”

Salyer has personal knowledge of the challenges faced by the transgender community. Her son has experienced barriers to care access when he has sought care for health concerns that do not align with his identified sex.

“He has spent countless hours on the phone with billing offices, clinical teams, and his insurance carrier to ensure payment to those providing his healthcare,” Salyer says.

As a patient access director, Salyer has seen similar situations arise many times. Recently, she asked other providers how they are registering this patient population in several national forums, but received only one response.

“Though the clinical systems have sections to alert team members of gender identification other than the assigned sex at birth, the financial systems are not quite so savvy,” Salyer notes. Here are some challenges:

  • Registration systems that only allow “male” or “female” as a selection.

The problem: If a patient identifies as male and legally is male but coming in for a hysterectomy, most systems would legally register the patient as male.

  • Post-service, an account edit would fail at coding for gender/procedure matching.

This means the coding team needs to change the sex to female to get the account coded. Once coded, the billing team would need to be alerted, as they may receive a “medically unlikely” edit, and would need to change the sex to allow for the claim to bill.

  • If the insurance lists the gender as male, there is still a chance of failure at the payer level.

“Edits may show that the procedure is not appropriate for the assigned gender,” Salyer explains.

System integration is another obstacle.

“Many providers these days have connected systems to physician’s offices and other data-sharing networks for regional medical record information sharing,” Salyer notes.

If any one of those systems is not prepared to handle gender identity issues, it could change the patient’s appropriately recorded gender in other systems.

“The transgender community hesitates in reaching out for much-needed care simply because they are frustrated with continually explaining themselves to the individuals involved in their care, financial team members included,” Salyer says.

To address this issue, she recommends the following actions for patient access:

  • Review the regulatory guidance associated with Section 1557 of the Affordable Care Act, and ensure compliance with the recommendations from the Office of Civil Rights (OCR).1

“Healthcare systems need to not only ensure adherence to the regulation, but provide seamless and compassionate access to care for this patient population,” Salyer says.

The language of the OCR document prohibits payers from discriminating against transgender individuals if they seek care for health issues that are provided to them appropriately, regardless of the individual’s sex assigned at birth, gender identity, or recorded gender.

For example, a covered entity would not be able to deny, based on the individual’s identification as a male, treatment of ovarian cancer if the treatment is medically indicated.

  • Train registrars to address the patient in their identified gender, without making assumptions.

For instance, a registrar might ask: “How shall I list your gender in our system?” Most don’t ask the question at all. Instead, they use documentation and visual observation to determine gender.

“Asking this question is not different than asking the ethnicity question. We should never assume,” Salyer says.

  • Work with vendors to address gender billing issues.

If the billing process is manual, Salyer says to build electronic flags in the system to populate work queues, or build claim edits to catch these accounts to reflect the proper gender for billing.

“Use regulatory language as a stepping-off point for your system vendors to change their systems to accept multiple gender codes, or to modify edits in the system for those traditional edits that may kick out due to gender-specific procedures,” Salyer suggests.


  1. Federal Register. Nondiscrimination in Health Programs and Activities, a Rule by the Health and Human Services Department. Issued May 18, 2016. Available at: http://bit.ly/2qJzT30. Accessed May 5, 2017.


  • Melissa A. Salyer, CRCR, Director, Patient Access, Chesapeake (VA) Regional Healthcare. Phone: (757) 312-6528. Email: Melissa.Salyer@chesapeakeregional.com.
  • Kathleen Shostek, RN, ARM, CPHRM, Vice President, Healthcare Risk Management and Patient Safety, Sedgwick, Chicago. Phone: (312) 521-9252. Email: kathleen.shostek@sedgwick.com.