Hospitals allegedly misreport gender transitions for minors as care for other medical conditions, new report finds

Medical providers may be fraudulently reporting sex-change treatments under unrelated medical conditions to secure insurance reimbursements, according to a new report.

“By hiding transgender procedures behind codes meant for other conditions, providers are – at minimum – skirting guidelines and ethical standards,” Dr. Kurt Miceli, chief medical officer at Do No Harm, said in a statement.

Doctors and prescribers are required to report every prescription, procedure or practice using a nationwide database of medical codes – currently the ICD-10 CM for the U.S. Under the roughly 70,000 diagnostic codes, F64 codes specifically categorize so-called gender affirming care treatments, Miceli told The Lion in an interview Tuesday. Such practices include prescribing puberty blockers, sex hormones and top and bottom surgeries to patients struggling with gender identity.

Do No Harm’s investigations

Do No Harm is an alliance of medical professionals and policymakers focused on keeping identity politics out of the medical field. In its Stop the Harm Database, the organization found nearly 14,000 children underwent various procedures, including 5,700 surgeries, for gender dysphoria, according to claims data from 2019 to 2023. However, Do No Harm discovered the medical listing often included other codes in addition to F64 – the gender dysphoria code –Miceli explained.  

In its most recent report, “Spotting Potential Fraud: How Healthcare Providers May Skirt Coding Rules to Get Paid for Child Sex Changes,” Do No Harm reveals various organizations are promoting these alternative codes, unrelated to gender dysphoria, to use for insurance reimbursement. Organizations promoting this medical fraud include Planned Parenthood of Southeastern Pennsylvania, Queer Doc and World Professional Association for Transgender Health (WPATH), according to the report.  

“These ‘loopholes’ may enable providers to get paid for procedures which otherwise may not be funded,” the report states. “In some cases, such practices may even be outright fraudulent or a means of evading state-level restrictions on child sex change interventions.”

The report lists eight medical codes misused for pediatric gender transition.

“The important thing to remember is that each of these codes also has legitimate use,” Miceli explained, noting the real conditions each code represents.

Endocrine Disorders are not Gender Dysphoria, Miceli says

QueerDoc notes on its website that some providers categorize gender transition under a code for an unspecified endocrine disorder, Miceli said. Endocrine disorders are various conditions of the endocrine system, which includes numerous glands and organs – such as the hypothalamus and thyroid – and specifically regulates more than 50 hormones. Conditions of the endocrine system can vary from diabetes to hypothyroidism but never includes gender dysphoria, which is best understood as a “condition of the mind,” Miceli explained.  

“The challenge here is compounded by the fact that, while there could also be a misuse of coding, the harms are being brought physically and emotionally to the children, who would be better served with psychosocial interventions for the struggles that they might be facing amidst gender confusion,” he said.

In a 2023 article for the Rhode Island Medical Journal, however, a handful of physicians recommended endocrine disorder codes as a “less stigmatizing diagnosis” for gender dysphoria, Miceli said. But providers are required to code “to the highest level of specificity,” which further demonstrates the fraudulent reporting many hospitals and other organizations are promoting, he added.

“This is driven by ideology, as well as being driven by securing payments,” Miceli said. “But it’s important to speak truthfully and to speak accurately as to the conditions that people have and not to be saying things that just aren’t the case.”

No FDA approval

The sex-altering drugs and procedures are legitimate aids for other conditions and diagnoses but are being used for so-called gender affirming care without the approval of the Food and Drug Administration (FDA), Miceli said.

“There isn’t an approval for gender affirming care,” he said. “It’s not completely unusual. Doctors do prescribe things off label. It happens frequently within medicine. But certainly, in this case, these treatments really are quite experimental.”

For example, a menopausal woman may need to supplement additional estrogen due to her body’s low production of the natural sex hormone. This hormone replacement therapy is valid and FDA-approved for such use. But prescribing estrogen to a young biological male who is struggling with his sexual identity should not be considered hormone replacement therapy, Miceli explained.

“There’s no hormone that’s being replaced, per se, because levels are what they are in a biological male, and they’re obviously significantly lower than what they are in a biological woman,” he said. “To call that hormone replacement therapy is really distortion and misuse [of the] code, if the care being provided is actually so-called gender affirming care.”

Strange patterns require investigation

There are other unexpected uses of medical codes that may indicate fraudulent reporting, Miceli told The Lion. For example, precocious puberty is the early onset of puberty and is typically diagnosed for young kids from roughly 6 to 8 years old. Using the medical code for precocious puberty for patients who are 13 to 15, or even in their 20s, is suspicious, Miceli explained.

The Department of Justice must hold medical providers accountable and investigate these suspicious patterns, Miceli said. Patient privacy laws may increase the difficulty of confirming providers’ fraudulent behavior, but often courts can demand medical records for ongoing investigations, he said, referencing a current Rhode Island case.

The DOJ is currently investigating Rhode Island Hospital for prescribing puberty blockers and sex hormones to minors – the same hospital whose physicians recommended using the unspecified endocrine disorder code for diagnosed gender dysphoria, Miceli explained.

Not only are providers fraudulently claiming insurance coverage through misappropriated codes, but they are also stealing taxpayer dollars that support insurance companies, Miceli said, specifically referencing Medicaid dollars as large sums of any state’s budget.

In February, Texas Attorney General Kent Paxton sued a doctor and pediatric hospital for medical fraud after the hospital performed gender transition treatments on minors and subsequently filed insurance claims with both Texas Medicaid and the state’s Children’s Health Insurance Program.

“Attorneys General auditors need to keep kids safe and keep providers from using alternative diagnostic codes,” Miceli said. “We should be truthful in what we are doing, not calling things something that they aren’t.”