HHS calls for increased scrutiny on claims involving gender-affirming care for minors

In a recent letter, HHS called on the Office of Inspector General (OIG) to examine healthcare organizations’ billing of gender-affirming care provided to minors. The department referred hundreds of facilities for investigation, outlining potentially anomalous billing patterns that it believes warrant further scrutiny.

This call to action stems in part from a controversial report that alleges healthcare facilities are motivated by financial incentives to provide gender-affirming care to minors, as these patients require “expensive drugs, surgeries, and lifelong medical interventions.” Commissioned by HHS, the report was authored by contributors affiliated with policy and advocacy groups that have publicly opposed gender-affirming care for minors, as well as physicians and writers who have criticized such care.

The report argues that claims data raise concerns that some providers may have used diagnoses that did not accurately reflect patients’ conditions to obtain reimbursement for treatment. Between 2015 and 2025, public and private payers were billed roughly $50 million for puberty-blocking drugs in patients aged 9–17 with endocrine disorder diagnoses, according to the report. In the same timeframe, these payers were billed $11 million for puberty blockers for hundreds of patients aged 13–17 with an ICD-10 code for precocious puberty. The contributors state that anyone over the age of 13 cannot have a diagnosis of precocious puberty, and therefore should not be given puberty blockers at that age for this indication.

HHS asked the OIG to review the following cohorts:

• Claims for puberty blockers with an endocrine disorder diagnosis (E34x) on the same claim with no gender (F64x) or precocious puberty (E30.1) diagnosis (2015–2025; patient age 9–17)
• Claims for puberty blockers with a precocious puberty diagnosis (E30.1) on the same claim (2015–2025; patient age 13–17)
• Claims for a primary gender dysphoria diagnosis (F64x) with a cross-sex hormone prescription written the same day, in a state prohibiting these procedures for minors, on a date when this restriction was enforced (2023–2026; patient age 17 or younger)
• Planned Parenthood affiliates identified by prescriber billing patterns

HHS’ letter and report mark only a few of this administration’s recent efforts to limit gender-affirming care for minors and reduce fraud, waste, and abuse tied to these services. Of note, CMS recently issued a final rule to prohibit Medicaid funding for certain “sex-rejecting procedures” furnished to minor patients, effective October 13.

As always, healthcare organizations must ensure claims are compliant. With a new spotlight on gender-affirming care claims, revenue integrity professionals should work with clinical and non-clinical teams to review billing, coding, and documentation practices. Take a closer look at the cohorts described by HHS and prepare for potential OIG reviews.