Mayo Clinic says denying non-contract Medicare Advantage patients access is not about money
Feb. 15—ROCHESTER — Mayo Clinic explains its decision to not treat out-of network Medicare Advantage patients is solely about "capacity" versus lower reimbursement rates.
"Mayo simply does not have enough capacity to serve an ever-increasing number of patients. Mayo needs to be good stewards with our contracted plans. This is what drove our decision to enforce our policy consistently," stated Mayo Clinic Spokesperson Karl Oestreich.
It was recently reported by the Star Tribune that some patients who are covered by Medicare Advantage insurance plans that do not have contracts with Mayo Clinic, like Minnesota's UnitedHealthcare, are being denied treatment. Mayo Clinic is "out of network" for those patients, so they can be turned away unless they show up at the emergency room.
The people being turned away are covered by plans that do not have a negotiated payment contract with Mayo Clinic.
Mayo Clinic did not confirm or deny if it is currently negotiating a contract with UnitedHealthcare. UnitedHealthcare is Minnesota's third-largest Medicare Advantage carrier, with 113,800 members.
Blue Cross Blue Shield Minnesota and UCare Minnesota, the state's largest local Medicare Advantage plans, are both in-network with Mayo Clinic.
"There was not a policy change, but a shift in enforcement to ensure Mayo has access for our contracted plans (not just Medicare) and those who truly need Mayo's medical expertise. This long-standing policy applies to all payers, not just Medicare Advantage," stated Oestreich. "Medical need, including the ability of Mayo Clinic to provide serious or complex care for patients, is the primary criteria for obtaining an appointment. In situations where medical need does not apply and to ensure appointments remain available for our Mayo Clinic patients, we no longer schedule routine visits for those whose coverage does not include Mayo Clinic. Continuity of care and relationships with existing local and regional patients won't be compromised."
Mayo Clinic did not answer questions about when the policy was originally adopted or why it was not enforced in the past, other than a growing need to now be "good stewards" with its contracted plans.
Statistics released by Mayo Clinic showed that the number of non-contract Medicare Advantage patients coming to Mayo for treatment has surged from 6,621 in 2019 to 10,260 in 2021.
In Minnesota, those numbers were 1,645 in 2019, increasing by 95 percent to 3,221 in 2021. Overall, Mayo Clinic saw more than 1.3 million patients in 2021.
One aspect that differentiates contracted Medicare Advantage in-network coverage to non-contracted out-of-network coverage is a new 2022 federal law that prevents "surprise" medical billing. That means an out-of-network patient cannot be charged more than the in-network rate their insurer would typically charge them.
"With non-contracted Medicare Advantage plans, there is no contract to protect the patient, provider and payer from unexpected situations. When these situations arise, there is an increased administrative burden to resolve issues," stated Mayo Clinic's Oestreich.
Health care economist Cheryl Damberg, who works for Rand Corp., commented to the Star Tribune that given Mayo Clinic's footprint as Minnesota's largest health care provider, clients often need access to Mayo Clinic for care.
"I suspect that Mayo is saying to United: If you want to send patients to us, you have to enter into a deal that is going to pay us some amount — and United is balking," she told the Star Tribune this week. "United is in a tough spot given expectations of Minnesota residents that they should be able to access Mayo."
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