One of the most prestigious healthcare institutions in the world is being sued by an employee who accuses the institution and its health insurer of ‘deceptive’ practices.
A civil lawsuit filed by an anonymous employee in Arizona alleges that Mayo Clinic and Medica Health Plan Solutions used “deceptive, deceptive, arbitrary, illusory (and) unpredictable” pricing and reimbursement models, which “constitute criminal activity.”
The lawsuit alleges that the Mayo Clinic, a top five hospital in the world, and Medica, the company that administers its self-insured health plan, purposefully blocked in-network services and providers from appearing in their online search.
When there were apparently no in-network providers available, the employee in the lawsuit said they had to use an out-of-network provider, which cost them more than $1,000.
Now the employee is claiming reimbursement for the money he claims to have spent on care that should have been reimbursed.
Pictured: Saint May’s Hospital, part of Mayo Clinic, in Rochester, Minnesota
The Mayo Clinic is widely regarded as one of the best hospitals in the US and consistently ranks among the top five medical institutions in the world.
The flagship facility is in Rochester, Minnesota, but there are several locations across the United States, as well as one in London.
Each year, the hospital serves more than 1.3 million patients at its locations in the Midwest, Florida and Arizona and has 80,200 employees.
The healthcare giant has 16 hospitals and 50 specialized clinics.
According to the hospital’s most recent financial reports, it had revenues of $18 billion in 2023 with income of $1.1 billion. The Mayo Clinic is a not-for-profit healthcare organization, meaning its revenues are invested back into the community, its staff and groundbreaking research and services.
Mayo Clinic offers self-insured plans to employees, meaning the employer collects premiums and reimbursements from enrollees, unlike a separate health insurance company.
This means that the company is responsible for paying the medical claims of employees and their dependents.
In the class action lawsuitfiled in U.S. District Court on April 2, the employee said they were looking for a psychiatrist after their son suffered a “mental health crisis” in 2019.
The employee went to the insurance company’s website and searched for child mental health providers within 50 miles of their home in Scottsdale, Arizona.
The search returned no results for in-network physicians who would be covered by insurance.
They decided to consult a doctor who was not covered by Mayo Clinic’s health insurance and submitted their bill to Medica for reimbursement. Their claim was denied, the lawsuit states, due to the fact that multiple providers were available in the network within a 25-mile radius.
Medica did not explain how these providers were found and why they did not appear on the employee’s provider portal, the complaint said.
The employee attempted to appeal Medica’s decision not to grant the compensation several times, but all were denied.
The lawsuit alleges: “Mayo and Medica are involved in an illegal “kickback” scheme in which Mayo and Medica take money given to them by plan members and illegally hold it for their own benefit, forcing (people) to pay twice for the same thing. Services.’
The complaint called the practices “mail and wire fraud, racketeering” and alleged violations of the Employee Retirement Income Security Act of 1974 and the Racketeer Influenced and Corrupt Organizations (RICO) Act, which is normally considered in criminal proceedings involving to organized crime. criminal entities.
The lawsuit asks Medica to take another look at underpaid employee claims, as well as transparency in processing insurance claims.
Medica did not explain why in-network options did not appear in the employee’s provider portal
This isn’t the first time Mayo Clinic and Medica insurance have been in the spotlight. Current and former employees not involved in the ongoing lawsuit spoke out Reformer from Minnesota in October, they sought providers of essential care outside their network or avoided medical care altogether for fear of what it could cost them.
One worker said he has had to cut back on counseling for his daughters’ mental health problems and has avoided seeing a physical therapist for his back pain, despite paying $11,000 a year for health care.
Another worker told the Reformer she was “terrified” about having to go to the hospital after paying $1,200 for a routine physical exam and blood work in January 2023, even though she said her state insurance benefits should be halved cover.
And a former employee is still paying back $10,000 in medical debt she incurred during her employment at Mayo.
The former employee told the Reformer that she switched to her husband’s medical plan, despite a $7,000 deductible, because there were doctors in the network she had access to.
She said: ‘I was bitter after that experience… You assume that the best hospital network in the world would, theoretically, take care of its employees.’
Another employee at the Mayo Clinic in Texas told the publication that she had to stop seeing a specialist after accepting a job at the institution and now has to drive more than an hour to see a doctor covered by Mayo Clinic Insurance.
While another said her inadequate coverage led to her receiving inferior care at a “super shady” clinic after Medica said the first location she went to was out of network.
She told the Reformer that she was still owed more than $300 and that she suffered complications after receiving stitches.
In a statement to DailyMail.com, Medica said: ‘As the administrator of the Mayo employee health plan, Medica is committed to helping Mayo employees understand their network care options and working with Mayo to provide its employees with the tools and resources to help them understand their plan .
“We will respond to the lawsuit, but cannot comment further on the lawsuit at this time.”
In a separate statement on this website, Mayo Clinic said: “Mayo Clinic is committed to supporting the health and well-being of our employees and their families. Our benefits plan is designed to provide flexibility to help our employees meet their healthcare needs.
“We are in the process of filing a motion to dismiss the claims against Mayo Clinic. We will have no further comment at this time.