Pre-authorization for fiancee’s surgery (Mayo Clinic)
Reposting from r/Codingandbilling.
Hi all. For the past week, I've been trying to wrap my mind around what the Mayo Clinic and my fiancee's insurance company (Allegiance) has been telling us. Here's the timeline so far:
About six months ago, she calls Mayo Clinic Phoenix directly, trying to get an appointment to get a birth defect she has fixed. She tells me that she dialed the scheduling line for the [Expert Doctor's Department], gave them her insurance identification number, and that they said that they are in-network with her insurance for the doctor she wants to see. About a month ago, we fly out there and she gets tests ran. The insurance company pays for the scans and diagnostics. Today, about a month from the surgery date, Mayo Clinic Phoenix runs pre-authorization for the surgery. The authorization is denied. I call various people and I hear tons of conflicting information: first, the insurance company tells us that Mrs. S from Mayo called the insurance company and concluded that my fiancee has the wrong type of plan (PPO instead of HMO) and hung up. My first call to Mayo (to billing) confirms that this happened.
I call another line (the pre-authorization department) and they give me a different story: they tell me that the insurance company said that Mayo Clinic Phoenix is in-network but [Expert Doctor] is out-of-network. I call the insurance back and they confirm this. We now have two conflicting stories. I then read this, saying that all doctors working for Mayo should be considered in-network if Mayo itself is, as all doctors at Mayo are employees instead of contractors. I call Mayo back (pre-authorization), and a representative confirms this (I have this call recorded, and she brought this fact up without me even prompting her) and says she'll contact Mrs. D in HR to get in touch with my insurance company and inform them that [Expert Doctor] is an employee of the hospital. Two days later, today, I call Mayo back and there is no update from Mrs. D. I call the insurance company and they say that Mrs. D. has not contacted them, and with the information they have, they cannot approve coverage for the operation, and that we'll have to submit an appeal at [Fax Number].
Last Friday, on the day that we got the estimate and the information that the insurance was denied, the clinic manager for [Expert Doctor] told us that we had until the end of the day to confirm that she is a self-pay patient. I told her that we would go through with the surgery either way (we will, as this is the only doctor she trusts), and managed to get us a few more days.
I'm wondering if anyone who knows anything about insurance can point me in the right direction here. Does any of this make sense? Is anything that anyone has told me true?
For reference, I'm 22 and my Fiancee is 21, so we're very new to this whole insurance game, and very reluctant to take on $166,000 in debt. Her insurance is a PPO through her father's work (O'Reilly's), which has no out-of-network coverage.
If you could answer these specific questions (WIP), I would be eternally grateful:
Is the information in the link correct: Does a doctor being an employee of a hospital mean that the hospital manages insurance contracts for the doctor? submitted by /u/connelliussen
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