Ability to self-refer to Mayo with Traditional Medicare
I have TRADITIONAL/ORIGINAL Medicare which allowed me to self-refer to Mayo Clinic. (People with Advantage plans have difficulty going outside of their network.)
I just received notice from my primary care clinic that my doctor is participating in a program within Medicare called "Accountable Care Organization, a Medicare Direct Contracting Entity (DCE). DCE is defined as a group of doctors, hospitals, and other healthcare providers who agree to work together to keep you healthy.
Apparently, the intention is to change the Traditional Medicare model based on "fee for service" to "quality of care" and one is assigned a network. Medicare has said it plans on transitioning all Traditional Medicare beneficiaries into such networks by 2030.
ANYONE FOLLOWING THIS CHANGE?
What happens to those of us who have doctors at Mayo Clinic because our networks lack expertise, technical capabilities and surgical capability to treat us? And what happens to Mayo research capabilities without sick patients from Medicare?
Interested in more discussions like this? Go to the Visiting Mayo Clinic Support Group.
I am not an insurance expert, but I tried to do some research on this seeing I am a Medicare patient that goes to Mayo.
The DCE programs appears to be something that continues to change, there were some announcements in March 2022 from Medicare about changes and new programs, but if you just got notified, the program your providers are participating in must still be valid.
I did find a Medicare document called: Accountable Care Organizations and You:
Frequently Asked Question (FAQ) for People with Medicare. Dated 2011.
At bottom of document, there is list of places to get additional information.
In document, there is a question / answer related to your concern:
Question: If my doctor’s in an ACO, can I still see whatever doctor I want?
Answer: Absolutely—if your doctor participates in an ACO, you can see any
healthcare provider who accepts Medicare. Nobody—not your doctor, not
your hospital—can tell you who you have to see.
I would contact your clinic and / or Medicare to verify that information above is still correct.
Thank you for your reply. I have contacted Medicare and my provider, and yes they say that I can still see a provider outside my network. But this initiative by Medicare is being done in stages (without approval from Congress). The question for you and me is what happens in the next stage. I was alerted to the implications by an article on Morningstar, an investment site (Title "Big Changes May Be Coming to Traditional Medicare" ). Here is the article :
Additionally, while my current clinic is a very large network, with specialists in every area, they do not have the capability/expertise to provide all surgical options or other treatments for cancer care. For example, I have lung cancer and at Mayo, I had Video Assisted Thoracic (VAT) surgery to remove a cancer mass and I was home in two days living independently. I was off pain meds in less than a week. If I had had open chest surgery, which they may not even offer to me because of my age, the time in hospital and recovery time would have been a very different situation!
My mother was diagnosed with Cholagiocarcinoma back in November 2021. She went through several procedures to drain her bilirubin and started chemo in December 2021; however, she had to stop chemo treatment in March 2022 because her bilirubin levels started to increase. It has yet to subside. She has gone through several procedures to clean stents/drain the bilirubin but the oncologist has told us they've exhausted all resources and can't fix my mom's issue anymore.
I want a second opinion and I want to go to the Mayo Clinic.
My mother lives in Boise, Idaho and the closest Mayo is in Phoenix.
She has Idaho Medicaid which won't cover if she's down in Arizona.
Can someone provide me information on how to navigate through the insurance to ensure she's covered under the Medicaid umbrella.
Also, I've been reading that patients could 'self-refer'. Because my mother as a state specific insurance (Medicaid), she needs to be referred by her oncologist?
I am wondering if she could just get admitted to the ER at the Mayo so she could be seen.
We are racing against time right now.
Any guidance would be appreciated.
Hi @danielywon, you’ll get the most specific answer according to your mom’s coverage directly from Patient Account Services at Mayo Clinic. They can answer all your Billing and Insurance questions specific to the Mayo Clinic in Arizona, Arizona regulations and her coverage and whether a physician referral is preferred or required.
Please contact them here: https://www.mayoclinic.org/patient-visitor-guide/billing-insurance/contact-us
Medicaid criteria may differ according to the campus you choose and the state Medicaid rules that govern.
Daniel, you may also wish to connect with other people with experience with cholangiocarcinoma is these related discussions:
– Cholangiocarcinoma – Bile Duct Cancer – anyone else dealing with this? https://connect.mayoclinic.org/discussion/cholangiocarcinoma-bile-duct-cancer-anyone-else-dealing-with-this/
Here is the link to the Medicare website on ACOs, although it could change over time. This is an issue I will personally follow and write to my representatives in Congress.
Hi janet23. Yes, tell your representatives in Congress!!! I started this thread because I became aware of the planned changes to Medicare through an article on an investment site. I also got a letter from my "previous" primary care provider telling me that she is part of an ACO and I "still have the right to self-refer to any doctor I wish".
In researching I found that Medicare will be transitioning all Original Medicare to ACOs over the coming years, because Medicare is changing how they pay – they will pay "by the head" and not "by fee-for-service".
QUESTION: Once the transition is complete to ACO with new payment structure (payment by head count), if you go outside the ACO for expertise who will pay them???? To me it seems that to maximize profits, the clinic has the interest to acquire as many patients as possible despite lacking sufficient number of doctors and expertise to meet patient needs. They will not want you to go outside their network of doctors and hospitals.
I need Mayo because I have a complex lung cancer, something Mayo is studying. Mayo's immediate diagnosis and prompt solution saved me a lot of grief and pain. My local clinic lacks expertise and solutions, but I could self-refer because I had original Medicare