How I Got My Referral To Mayo

[Lemons2lemonade]

A lot of people have been asking me this, so i thought i would share:

My parents work for the school district, and i am under their insurance which is an HMO.

Since i have had pots, there have been four different doctors monitoring my condition.

-My general practitioner (who i see for my bags of fluid/ typical care, we get in a lot of arguments)

-my cardiologist (who i talked to more often while on beta blockers, and also who i call when my pulse/bp acts funny)

-my internal medicine doctors( who are the on call doctors in the hospital. They run all of my obscure requests for blood work, regulate medication dosages, and communicate between other specialists, they are kind of like my advocates. If i get admitted to the hospital, these are the people who come to see me, and find a treatment plan for my discharge)

-my neurologist (who basically threw up his hands and caved on writing a referral)

He wrote the referral and expressed some concern about its being approved. The referral went something like this-- lemons is approved to go to mayo clinic for the following: blood work, 6 consultations, minor lab work, and x-ray. The scope of this referral was limited and i wish i would have known then what i know now about tests that would be performed. The language did not include my emg, evoked potential test, autonomic reflex scan, holter monitor, and also to speak to a GI dr. down there for my issues--a referral that dr. g wrote.

After making some phone calls, i learned that mayo would not tell me the tests to be ordered until i saw dr. g. I talked to the secretary in dr. G's office, dr. G's nurse and also mayo's preapproval department in search of these variables. The last phone call i made was to my insurance company to tell them that i could not retrieve this specific information from mayo, and i wanted to ensure that the needed tests would be covered. A representative assured me that needed tests would be covered. I took down the representatives name, the confirmation number of the call and also the date/time of the call. I also took down all of the info of my calls with mayo.

This information, and this double checking are possibly the only reasons i was able to be seen. If i had not have documented these conversations and had the confirmation number of my referral approval, i doubt my referral issues while down there would have been resolved.

During this process, i learned that when my dr. writes a referral it goes to a medical director/medical board who determines whether or not it will be approved. If one of my referrals is denied, there is an appeals process to go through, where i can contest this decision.

[Lemons2lemonade]

while i was in arizona, i had to write a request for an expedited appeal, this is a copy of that e-mail, i have edited out information, shown in brackets, to conceal my identity and the identity of my insurance company:

"I am writing this from Scottsdale, Arizona, where I have already purchased a plane ticket, hotel and car rental in reliance upon on a referral from [insurance company] to the Mayo Clinic that was previously approved – in writing - and then was apparently subsequently either revoked or otherwise limited to exclude the very tests and services I was advised by my doctor to come here to have done. This apparent revocation was apparently done without my knowledge and without informing me in any way prior to my trip; I did not even learn of this until I was already at the Mayo Clinic in Arizona and was advised that there was an insurance coverage problem by someone at the Mayo Clinic. It was only after I contacted [insurance company] customer service to inquire about the issue that I learned (after speaking to no less than five different representatives and their supervisors) that my referral had been revoked and/or that the necessary tests would not be covered. As I have already relied upon the written referral and [insurance company's] oral assurances that all of the tests recommended for my condition would be covered under my insurance, and these tests are necessary for my health, I respectfully request that [insurance company] cover the tests recommended by my assigned physician at the the Mayo Clinic. Moreover, as I have already invested a substantial sum of money in getting to Scottsdale, AZ – money I had to borrow from my parents, as my medical condition has prevented me from working this entire time and I have very limited financial resources – I would request that this appeal be expedited so that this matter can be resolved promptly, before my scheduled return to Washington on February 20.

I have been suffering from autonomic dysfunction and postural orthostatic tachycardia syndrome for over five years. After several misdiagnoses, it was finally diagnosed as this condition in 2010. It has been a debilitating condition for me. I cannot work. I experience traumatic and disturbing physical symptoms that require me to seek emergency medical treatment quite often due to their severity and similarity to a life-threatening problem. At times, I have problems standing up for more than ten minutes. This is, quite frankly, made my life incredibly difficult for several years. I am eager to try to get it resolved and live a normal life, and was extremely hopeful that this time at the Mayo Clinic would be a step in the right direction.

After extensive research on my part and consultations with my doctors, it became clear to me that this condition is not widely understood by the medical profession. It is, in essence, an illness that very few doctors have experience with, and one that necessitates certain tests that very few facilities have the ability to perform. One of the few facilities in the country that does have the ability to do these tests is the Mayo Clinc in Arizona. Because of this, my neurologist, Dr. [x] strongly recommended that I come here, to Scottsdale, AZ, for a consultation with a doctor who is an expert with this condition and to have additional testing done.

At the recommendation of Dr. [x], I sought a referral to the Mayo Clinic, which is renowned for having experience with this unusual and misunderstood condition. I received a referral in writing from [insurance company], so I booked a trip to Arizona to have the recommended tests – such as an autonomic reflex screen. I even contacted [insurance company] before the trip to confirm that these services were covered and was assured that they were. Thus, imagine my shock and surprise when I arrived at the Mayo Clinic only to be told that “there was a coverage problem” and to find out that the referral had either been revoked or narrowed to exclude the very tests that I was here to get (tests that the Mayo Clinic has the facilities to perform, as far as I am aware).

In trying to resolve this problem, I have spent hours on the telephone with various representatives of [insurance company]. Some have informed me that my initial referral to the Mayo Clinic was unilaterally rescinded; others have informed me that the referral is still active, but that – despite the broad wording of the referral – certain tests are not covered because “[insurance company] can do these tests.” However, there are multiple tests that my doctors have recommended – including the autonomic reflex screen – that [insurance company] cannot do, according to everything that I have been told. Even after all of this, one of my internal medicine doctors – Dr. [y] – has indicated that these tests are necessary for me and that he believes I should be able to obtain them in order to try to resolve this medical problem.

Frankly, I feel that it has been borderline fraudulent – if not actual or constructive fraud – for [insurance company] to issue a written referral to me and tell me that these services are covered, wait until I have spent a significant amount of money coming to Scottsdale in reliance upon the assertion that these services would be covered by my health insurance, only to find – after I was already at the Mayo Clinic and had received an initial consultation – that the approval was essentially revoked or would not cover the very tests that I was advised to get and came here to get.

Moreover, I fail to see anything in my insurance agreement that would plausibly permit [insurance company] to issue me a referral – which is defined in the plan documents as “an agreement” – and then unilaterally revoke it or limit its scope without even informing me. I strongly suspect that an attempt to do so constitutes a breach of my insurance plan agreement. I am simply asking the [insurance company] honor the insurance agreement.

Quite frankly, while I would certainly wish to avoid this route, should my appeal be denied, I feel like I have no choice but to seek legal counsel, contact my local legislative authorities and contact the local press to describe exactly what has happened here. I simply cannot see how this coverage denial and/or revocation – apparently at the very last second - could possibly have been made in good faith, especially considering it was already approved at one point. Moreover, I fail to see how this could be done without even informing me until the very date of my first appointment in Arizona.

In conclusion, please consider my appeal in an expedited fashion and overturn the denial/revocation of coverage for the tests recommended by the Mayo Clinic. All I want is to have these tests so that my health can, hopefully, improve and I can try to live a normal life. I have already invested a significant amount of time, money and resources in this trip and would hope that this can be resolved without much more difficulty. Thank you for your time and consideration."

The following day, dr. g's nurse called me stating that she received a "bizarre" phone call from my insurance company. Following our discussion, all of the needed tests were approved.

[RunningWild]

Im curious why it was such a hassle to get in to be seen by Dr.G.

My EP wanted me to go to Cleveland Clinic for some more testing/to speak with someone that knows what theyre talking about- and this was as simple as calling that Drs. Office, and asking for an appointment.

Its weird that its not always this easy? Huh.

Anyway, I have appointments and tests next week at CC.

[Lemons2lemonade]

nice, guess my insurance company isn't as good

[RunningWild]

Ah I guess i misunderstood what you were saying- that it was difficult to get a referral. Nvm. Insurance companies can be tricky.

[sue1234]

I think it is due to lemons being in an HMO. I am in a PPO and I don't need referrals and was able to call Mayo and they literally asked "when would you like to come in?". Now, having said that, I may find out my insurance claims the tests were not necessary or some dumb thing like that!

[Lemons2lemonade]

sue, what is a ppo?

[McBlonde]

Great appeal, Lemons! I have to say, that referral that neuro wrote is one of the worst I have seen!! I was in the "business" 20 years and I bet dollars to donuts that is a capitated HMO. That means.... there is 1 amount paid for each patient per month. If they refer you out of their system....it comes out of their pockets... sad it works that way, isn't it?

Another IMPORTANT thing you said is that you are on your parents's insurance still. THAT is a huge blessing and one of the things to know when elections roll around. So many young people with pre-existing conditions are able to stay on their parents ins now, and I hope that part of the affordable care act doesn't get appealed. Before that law came info effect, my daughter, who turned 26 was dropped from our insurance and THAT was terrifying.

I forgot.... Does anybody know if Mayo accepts Medicare as primary now?

Thanks for the info!

xoxo

[Lemons2lemonade]

Mcblonde, thank you, and yes i am very lucky that this bill was passed. Also i turn 26 this year, so happy birthday to me, no more health insurance

[McBlonde]

Ok... let me think, lemmons.. That's where we were...

1st, when my daughter turned 26 ...she had to go off of our insurance, but WAS able to get COBRA... a continuation of our insurance which cost us through the nose, but worth it if your child might need heart surgery AND then IT ran out.

What happens then is you have to apply and be denied for insurance......WAIT 6 months without any insurance then at 6 months (depending on your state) you can apply and get coverage again under the ACA. We have 2 1/2 months to go. I say my prayers every single day that we make it.

[sue1234]

All I know is PP stands for Preferred Provider. Don't really know about the O. It is a self-bought policy, have had it for probably 15 years. I pay through the nose for it, but we have our own small business. I believe an HMO is provided through employment at companies.

[McBlonde]

These are managed care terms: PPO = a preferred provider organization. An HMO = Health Care Maintenance Organization .. The HMO is cheaper, BUT the primary care doctor controls everything.. With the PPO, you don't have a "gate keeper". You can go to whoever you want that is listed in your network and also you can go out of network, but you will have more out of pocket expense.

here's a link for explanation

http://healthinsurance.about.com/od/understandingmanagedcare/a/HMOs_vs_PPOs.htm

[sue1234]

Yea, I can see where each (HMO and PPO) have their advantages AND disadvantages.

[Lemons2lemonade]

thanks for the info!

[McBlonde]

Yea, I can see where each (HMO and PPO) have their advantages AND disadvantages.

Exactly! If you have a FABULOUS primary care doctor..... well, that helps so many things. The problem in my area is the PCPs are all more "doc in the box" 5 minute visit types... which doesn't work too well for me.

[momdi]

Mayo's policy on Medicare is on their website. They don't accept it, but they do, if that makes any sense. If you are medicare, you will end up paying more out of pocket than if you're not, but they give some pretty detailed examples, which make a lot more sense than trying to describe it in the abstract. That said, that policy applies to specialists.

Mayo hospital accepts medicare.

Mayo primary care does not accept medicare.

Hope that helps rather than adds confusion. Check out their website for full and current info.

[McBlonde]

It does... thanks!!