You got me curious, so I went and checked the MoZaic FAQ page. Regarding letters, it stated the following:

“Pre-op insurance requirements?
Insurance companies generally follow WPATH guidelines. WPATH guidelines currently require 2 letters from providers, one can be your primary care or hormone specialist and the other from a mental health specialist.
However, many insurance companies follow the previous WPATH recommendations of 3 letters: 1 from your hormone specialist and 2 mental health letters from 2 separate mental health providers. For more details on the letter requirements, please go under our new patient tab and choose the letter option.”

When you go to the New Patient Tab, you find the following:

“Scheduling Surgery
During your consultation or follow up visit, we review your medical/surgical history and perform a physical exam, followed by an in-depth discussion of surgery, if indicated. Within one week of most consultations, you should be contacted via email by our OR scheduler. Once you have submitted the required letters requested by insurance and WPATH, a surgery date can be secured.
​
Starting about 3 months before your surgery, we will contact your insurance company to start the authorization process. You will then be contacted with pre-op and post-op appointments, and you will also receive pre-op/post-op instructions and other related paperwork. Please do not make non-refundable travel plans, as insurance does not allow authorization prior to 90 days before surgery, and the occasional instances of insurance glitches can arise that require rescheduling surgery.
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IMPORTANT NOTES:
Insurance companies require all letters be dated within 12-months of your surgical date. Please make sure all your letters are signed and dated by your providers.
Surgeries are scheduled by first having a discussion with your surgeon. Your surgeon will then contact the OR scheduler and notify them on what procedures to schedule.”

If you read the requirements carefully, you discover several contradictory things. First, the site does say that letters have to be in hand before surgery is scheduled and that there may be 2 or 3 letters required depending on the insurance. It then says that letters must be dated no later than 12 months before the surgery. Finally, it says that the procedure will not be submitted for insurance coverage until 3 months before the scheduled date, since that is the earliest that insurance will approve it.

Reading all these things together, they only make sense if the actual surgery is performed within 12 months of the initial consultation if you take them at face value. People who I know who have approached Heidi in the last year or so have been quoted wait times as long as 3 years (notwithstanding the shorter scheduling times described on the website). Marci Bowers is even worse at up to 5 years (though if it were my choice I would use Heidi since she has better skills in spite of Marci’s experience and reputation). With these kind of wait times, the written protocols do not work if interpreted to literally mean that nothing will be scheduled with the patient until letters are in hand (and by implication insurance approval obtained).

With both surgeons potential patients are told to get on the wait list to preserve a slot. Assuming that scheduling is more than a year out, there is no way to have letters in hand unless one were to get them twice—once to schedule and once to avoid the staleness problem—obviously an unwieldy solution.

In my case, I approached Heidi in July 2020. She immediately scheduled me for the end of April 2021. I did not need letters, but was informed in writing that I had to have them (3) in place at least a month before the procedure. Shortly after I scheduled it, I unexpectedly went through a series of five eye operations, and one heart procedure which forced me to push things off. I had a second consult with Dr. Boddington a couple of weeks later, who had just joined Heidi‘s practice. He informed me that the earliest they could reschedule the surgery would be October, 2021, about 14 months away. I was not asked for letters, and had I been, they would have been stale by the time I actually had the surgery. I ultimately provided the letters about the time of my 2 1/2 month preop in mid July 2021. Everyone was happy with the arrangement.

In Jen’s case, she provided her letters about 3 1/2 months before her procedure. Insurance did not even approve it until the week of when it was to be performed. Apparently that is quite common in New Jersey. The surgical staff seemed unconcerned. The bottom line , and the reason I commented to Amber, was to advise her to approach surgeons early in case there were extended wait times. It would be an unpleasant surprise to have everything mentally scheduled and approach the surgeon too late to meet what you were counting on. Contacting potential surgeons years ahead of time is a smart move to make sure what the wait times look like and to identify any issues that may arise regarding insurance or letters. It also allows you to get on the waiting list to reserve a slot. I was just suggesting that she plan ahead more than she might think she needed to.

Obviously different providers and hospitals have different requirements. Another thing people have to consider that they frequently don’t (I didn’t) is that the hospital bill likely will be much higher than the surgical bill. You have to make sure that is covered as well to avoid an unpleasant surprise. My hospital bill was $58,000 and I had to pay it out of pocket before I automatically got it reimbursed by Medicare about a month later. Good planning can avoid these kinds of issues. In this regard you should also allow 6-12 months for hair removal depending on the surgeon’s requirements. Heidi’s were quite elaborate, Dr. Keith’s less so. He did residual hair removal as part of Jen’s surgery.

Addendum: After I wrote this I checked the Letters tab in the New Patient Section. The first item reads as follows:

“Letter Requirements

CONSULTATION: Letters are not required, but recommended for the consultation.
…

SURGERY SCHEDULING: In order to secure a surgery date, you will need to submit the letter requirements indicated below. If you submit your letters prior to your consultation, please be advised that they must be dated within 6-12-months of your surgery and will need to be revised.”

It is shortly after the consultation (within a week or two) that a tentative surgical schedule will be established with the hospital. At the initial consultation inquiry can be made as to the requirements surrounding the potential surgery including things such as probable date, BMI, medical clearances (including blood tests and scans) and timing, WPATH letters, hair removal etc. The actual scheduling of OR space is of less concern to the patient. It is reasonable for the patient to expect that things will go off as tentatively scheduled by the practice with them barring a last minute insurance issue. This was what I was referring to when I talked about scheduling, not the technical distinction of the actual schedule set between the doctor’s office and the hospital which does not involve the patient and which is where the letter requirement kicks in. Essentially scheduling is a two part process. A tentative schedule is set with the patient at the initial consultation, or shortly thereafter once the hospital has been contacted. Then when letters and insurance approvals are in hand the scheduling is formalized with the hospital. That is where they become necessary.