Autonomic Disorder and Coverage for Mayo's Pain Rehab Program

Hi everyone,
We were recently at Mayo for eval on multiple symptoms/conditions. Everything covered in network. Two MDs recommended Mayo's Pain Rehabilitation Program: https://www.mayoclinic.org/departments-centers/pain-rehabilitation-center/sections/featured-programs/gnc-20481713.

Insurance preauthorization said $30,000 of the program isn't covered. Which makes no sense, because the program services are part of our covered benefits. I was told the coding Mayo is using is the issue. And that the services shouldn't be coded that way according to the AMA (which oversees coding changes and guidance).

I let both MDs know--one called me directly and said they would help in any way they could.

Has this happened to you or anyone you know? Were you able to resolve it? and how?

I have considered applying for "financial assistance." In part because I can't afford $30K. Our medical expenses (including related travel) this year have been through the roof. And in part because my insurance should cover this but for Mayo's coding. We have excellent medical coverage, with behavioral health covered equally.

If you don't want to respond publicly, please feel free to send me a private message.

thanks--

Hi everyone,
We (my teenager and I) were recently at Mayo for eval on multiple symptoms/conditions. We have excellent medical coverage, with behavioral health covered equally. Our insurance covered everything in network.

Two MDs recommended Mayo's Pain Rehabilitation Program: https://www.mayoclinic.org/departments-centers/pain-rehabilitation-center/sections/featured-programs/gnc-20481713.

My teen wants to do it because, well, medicine alone isn't going to fix things. I don't want to lose this momentum/opportunity for my kid to start feeling better and living a more regular life.

Insurance said $30,000 of the program isn't covered. I was told the coding Mayo is using is the issue.

I can't afford $30K. Not sure if financial assistance would be worth applying for. Anyone have experience with that?

and any suggestions on the coverage/coding issue?

thanks–

Hi @kari3057, I can see that you are concerned about coverage to be able to take advantage of Mayo Clinic's Pain Rehab program. You posted multiple messages in several groups, which I have merged into one discussion that appears in the Chronic Pain, Depression & Anxiety and Visiting Mayo Clinic support groups simultaneously. That way you don't have to monitor 3 different discussions.

The best ways to get direct answers about billing and coding related to Mayo Clinic and your insurance is to contact Mayo's Billing & Insurance department on Monday https://www.mayoclinic.org/patient-visitor-guide/billing-insurance/contact-us

In the meantime, let me connect you with other graduates of the Pain Rehab Center (PRC) at Mayo, like @rwinney @sophiaaa @skier @boltz7555 and others so they can share their experiences both with paying for the program as well as their outcomes.

Which location are you and your son hoping to attend?

Hi @kari3057, my apologies for the delayed response to your question about Mayo insurance coverage and your daughter attending the Pain Rehab Center.

First off, I'm sorry to learn your teen is going through this at such a young age, but how incredibly proud you must be that she understands this early in the game that medicine alone won't fix things. So very true.

While I don't have experience with financial assistance at Mayo, I did have to wait to attend the PRC program until my insurance open enrollment time when I switched to a plan that covered out of network care as I'm from NY and went to Florida's PRC. Which PRC is your daughter looking to go to?

You mention coding being the problem. I agree with Colleen, dig right in and contact both your insurance company and Mayo to understand as much as possible and find out what needs to be done to make it work. I can attest that having your daughter attend the PRC program will be a life changing experience for her. It is an amazing program that really helps turn lives around.

Have you had a chance to contact Mayo's billing and insurance yet? How'd you make out?

Hi Rachel, thank you for the response.

I haven't made much progress. (and this is an overdue post, thank you Colleen for the earlier response--I have been working on both fronts in the meantime and was hoping to have more positive news to report)

Mayo precert/insurance says they can't make a precertification request due to their "billing code." (so how are exceptions ever considered? it can't be impossible...)

Carefirst (a DC area BCBS plan-- in network at Mayo etc.,) says Mayo must make a formal preauthorization request. Without an actual request they have no question to answer. I need Mayo to make a formal request. Not just call and ask questions.

Our BCBS case manager says they have no record of Mayo making a request. They do have a record re the PHP my teen did this spring (which was fully covered). Until Mayo makes a formal request, BCBS has nothing to "consider."

My guess is that Mayo bills this as predominantly medical (it's pain relating to a medical diagnosis). The program includes behavioral health components (group therapy etc). Because Mayo codes the 5+ hours of daily behavioral health as medical it doesn't fit the typical A, B, C process. But we have coverage for medical and behavioral health. And Mayo is in network (our week of visits in October cost me very little yea!)

If Mayo spoke with a BCBS "behavioral health" precert specialist or someone higher up they could solve it. Or at least get past "no" and submit the necessary "formal" precert request. Without a formal request, BCBS has nothing to evaluate.

I need Mayo to make a formal precert request. I can't do it. My son's case manager at BCBS can't do it. She said they can work this up the chain, but not without a formal request. And Mayo hasn't made a formal pre-cert request.

I need Mayo to not give up after the first phone call (which is why I'm spending my saturday reasearching and writing this). If the first phone call doesn't work, it needs to be elevated. My BCBS plan covers this but I can't make it happen. Without Mayo's formal precertification request, our case manager and her supervisor can't either.

We all know a single phone call won't resolve complex health coverage issues. Patients can't accept the first no as end of story. Patience, persistence, tenacity, and staying calm when you want to scream or throw your phone out the window. I think we can all relate.

I don't give up when advocating for my son (I even sued the school district this summer and got everything and more that he needed re his IEP--yea!!!). I don't give up at work either (I litigate $$$ cases for the US government (and for all Americans).

I don't give up until there is nothing more that can be done. (and it's horrible how much time it takes--as a single mom with a FT+ job, my time should be spent with my kid or taking care of myself, not getting more stressed over Catch-22 issues like this)

If i could do it, I am 90% sure I could do it. I could at least get beyond the first "no" and submit the required formal authorization request.

How do I get Mayo precert to get beyond the first phone call? How do I get them to submit a formal preauthorization request?

thanks,
Kari

PS. I found this online--if I can find this, there must be more where that came from (and this is public info, not behind a provider/insurance firewall):

Advance Benefit Determination
Providers may request an Advanced Benefit Determination (ABD) for certain services...
...providers may contact CareFirst’s provider services line to initiate an ABD request.
 Maryland: 800-854-5256
 Washington, D.C./Metropolitan Area: 202-488-4900

Hi Colleen, thank you (and I thanked you in a related response to my post)

My son wants to attend the Rochester program. (and bring his snowboard for the weekends :). We have family in the Twin Cities and Madison so we could see them as well.

in the meantime, I've spent more time researching and on phone calls.

I need Mayo to submit a formal preauthorization request to my insurance company. They haven't done this. Without a formal request, CareFirst BCBS has nothing to consider/authorize. Our week of Mayo appointments in early October were fully covered. (my only bill is a $35 copay.) which is why this is so bizarre.

We have a case manager. She and her higher ups are willing and able to help but they can't do anything without Mayo's precertification request. They can see a precert request from another provider from the spring. But BCBS has no record of a Mayo precert request.

I spoke with Mayo's precert team and was told they couldn't make a request. But BCBS evaluates preauthorizations/pre cert requests. and they make redeterminations if denied. They can't do anything without a formal pre-cert request.

I can't make the request. My case manager and her bosses also can't.

How do I get Mayo to do it?
thanks,
Kari

Hi Kari,
It sounds like you have already spoken with a coordinator at Billing & Insurance
- Patient Account Services toll free at 844-217-9591 Monday through Friday

I have a couple of suggestions:
1. Request an appointment with a Mayo Clinic social worker. They can often act as mediators with challenging insurance cases.
2. Contact the Office of Patient Experience
If they can't directly help you, they can direct you to the right place internally at Mayo Clinic to get the help you need.
Mayo Clinic Office of Patient Experience
https://www.mayoclinic.org/about-mayo-clinic/patient-experience
Phone: 844-544-0036 (toll-free)
Email: opx@mayo.edu

Well, you are certainly on top of things with no grass growing under your feet. I'm hoping persistence and self-advocacy prevails and your son (not daughter 😉) has the opportunity to attend PRC.

Granted insurance approval drives the bus, but are you in contact with a Pain Rehab Center representative? Might they be able to offer insight as to why Mayo hasn't made the pre-cert request yet? I found my rep to be very helpful in many aspects.

How does your son feel about going to a pain rehab program? Has he researched the fundamentals of how his time would be spent during the 3-weeks of rehab?

Thanks for the support and suggestions. We learned about and were excited re the program in early October during our week at Mayo. He understands and wants to do the program (he missed 1/2 of school last year and wants to be a "normal" teen--not feeling sick most of the time).

an update. we have been trying to attend since mid-October. We were "qualified" by medical 10/13. Because of the holidays, we wanted to attend end of October. Short version: Mayo still hasn't submitted all of the codes they need approved--and finally told me so this week.

Starting in October, Mayo precert kept telling me they couldn't submit a precert request. It was "impossible."
My case manager said she couldn't help us without a Mayo precert request. I kept calling Mayo, BCBS, and posted here for help. (and the Mayo person kept leaving work early so i could only leave messages)

Mayo precert finally submitted the request November 6th. My insurance approved it that same day.

I learned of the approval when talking with our BCBS case manager the following week (nothing from Mayo). She gave me the authorization # and name of approver. along with the codes Mayo submitted. I started trying to get my son scheduled.

I contacted Mayo precert. they told me the BCBS approval wasn't based on accurate info.

I contacted BCBS--they said they approved the diagnosis/procedure codes Mayo submitted. BCBS contacted Mayo precert directly to explain the approval. (I did this three times because Mayo precert wasn't "convinced.")

Finally last week Mayo Precert admitted that they didn't include the correct codes in the November 6th request. And they would resubmit another precert request with the missing codes. (and complained about how hard everything was... I asked that we focus on solutions and stop complaining)

My teenager is still missing school bc of health issues.

And financially, the cost/out of pocket in January will be so much higher than in the 2023 plan year (deductible to meet, max out of pocket etc that will be reached this year). How can i get Mayo to submit the correct codes and authorize/schedule the program now???

I am beyond frustrated. Refusing to submit a precertification request to my insurance. When it's approved, not letting me know. And now, when I try to schedule, I learn Mayo "forgot" to include all of the correct codes. and will need to submit another request but can't give any information on when that might happen.

Should I just give up? Is there a supervisor or someone with more experience/problem solving ability who can step in? I have spent so much time trying to solve this (and I have a FT+ job and a kid who needs me). and i'm the one financially impacted. I wish I could use my focus, patience, energy and solution-oriented approach to fix this mess.

any suggestions are appreciated, thank you

(and my immature comment--i am out of patience listening to her complain about how hard her job is)

@kari3057, I understand your frustration. This does appear to be much more difficult than necessary. If you haven't done so already, it is time to contact the Office of Patient Experience to help intercede on your behalf.

Mayo Clinic Office of Patient Experience
https://www.mayoclinic.org/about-mayo-clinic/patient-experience
Phone: 844-544-0036 (toll-free)
Email: opx@mayo.edu

I'm also sending you a private message.