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Jul 4, 2018 · Insurance denied my claim in Just Want to Talk

@salwaebrahim, I can relate to your frustrations on a personal and professional level. I have had multiple claims denied by insurance company. With the help of my physicians we were able to overturn decisions, but unfortunately not all.
I currently work for a large healthcare organization in the Utilization Review Dept, formerly an ICU nurse. I review hospitalized patients and submit clinical to payers of all type, gov't and private. It's a growing trend for payers to deny despite the proven necessity of treatment.
You have the best physicians, Mayo, appealing the denial. If for some reason the decision stands despite Mayo's effort, you as the patient still have appeal rights.
Many insurance companies offer as a final patient appeal the opportunity to have an outside physician reviewer, one who specializes in the field and not affiliated with the insurance company review/determine your case..
Unfortunately, it's a stressful process. While Mayo's appeal is ongoing, I would make sure you're kept current on determinations and receive copies of all decisions. A determination comes with an explanation for denial….procedure not covered within the plan, experimental, not medically necessary to name a few. By knowing the train for denial, helps you prepare in case you must appeal as a patient.
Any questions or further info needed, let me know. Best of luck.

Sep 17, 2016 · How to get the most out of a visit? in Visiting Mayo Clinic

Hi @lorri, I also would encourage another visit to MC. I have BCBS and never had any difficulty with medical claims from MC visits. I did have genetic testing that MC sent out. Since test would be billed by outside facility, I was asked to sign a form that if insurance denied payment then i would be responsible for payment. I was informed that if denied, MC would assist with providing records, medical literature to insurance to help get the claim paid.
Unfortunately, in the past I too had a disappointing visit. It was a follow-up after several prior visits for a neuromuscular mystery. I didn’t receive a diagnosis or recommendations for further care. A complete medical work up was performed over the period of 6 months. The disappointing experience was with a neurology fellow, who did not remain at MC as an attending. When he had no answers to give me, he was at a loss in providing any options for me to pursue. In hindsight, I should’ve insisted on speaking with the attending physician. I was contacted by phone, by the end of the call I was a bit distraught. That experience did not tarnish my respect for MC. During those visits, I had met so many outstanding and compassionate physicians, nurses and ancillary staff that helped me in many other medical areas. The disease that MC couldn’t diagnose was ultimately investigated at the NIH. The disease is very rare, with very few specialists able to manage it. Unfortunately, one is not at MC. I’m glad I didn’t give up on the Clinic. I have returned many times since for other medical problems arising from this disease, will return again at the end of Sept. MC may not have diagnosed my illness, but the many physicians and staff have greatly improved my quality of life by diagnosing and treating the cascade of other problems the disease causes. MC has been the only medical facility (besides NIH) where I’ve always been treated with respect and compassion. I’ve learned many things through this medical journey. A few are…don’t be afraid to ask the physician for a referral to another medical center if unable to treat you. Request and keep all records of test results whether or not abnormal. I was overrun with paper copies, that I now scan all results to flash drive and organize by dates/categories. This way records can be easily retrieved, printed when you need them. Request films or CD of any radiology tests along with the reports,. Keep journals of medications or therapies tried and any positive or negative effects. Lastly, keep a daily log of symptoms, anything that may help or worsen symptoms- weather, exercise, amount of sleep, diet, etc. By logging this, there may be patterns that were missed. Just a few things that have helped me. Appointments with specialists can be overwhelming. Many times patients think of questions after they’ve left the office, which makes it difficult to get answers. Going to these appointments well prepared with the medical data and a list of questions, may help the visit be more productive. Lastly, MC is very efficient with utilizing prior results if they’re deemed of good quality, not ordering tests just to repeat them. That’s why the CD for CT scans, xray, mri is important. MC radiologists will read it themselves. This practice decreases unnecessary testing that has the potential of insurance denial.
Sorry for the length. I hope this helps and your husband gets answers.

May 18, 2016 · Insurance Question in Visiting Mayo Clinic

I’ve been fortunate that I’ve had little difficulty getting everything paid
for during Mayo visits.There were 2 times when insurance denied, genetic
testing and a test very few centers perform. Mayo sent additional
documentation defending rationale for testing and both were covered without
intervention by me. I’m actually a nurse and started working in Utilization
Management in a hospital shortly before my first Mayo visit and have
learned much about claims, coverage, denial process and physician
documentation. Also, unfortunately it seems lately the trend of insurance
companies is leaning towards denials. I continue to be followed by Mayo
physicians and at times wonder if a test will be paid for, but I wont late
that deter me from proper medical care. Except for MRI, CT scans outpt
testing needs no prior auth with my insurance plan, but that doesn’t mean
it will be covered. Its all based on plan coverage and what is deemed
medically necessary by insurance company’s physician advisor. With the
genetic tests, I did sign a form stating that I would be financially
responsible if not paid for by insurance, but Mayo would assist with appeal
if needed, which they did. Bottom line is, I don’t think there is ever a
guarantee of full payment. In my experience, I’ve not had any unecessary
tests performed during my Mayo visits and continue to trust their judgement.

May 18, 2016 · When is chemo done before breast surgery? in Breast Cancer

Yes, it can be appropriate to have chemo prior to surgery for not only
breast cancer, but other cancers as well such as colon. Is not necessarily
standard though, the toe of cancer along with known extent if disease is
considered as well.

May 18, 2016 · Did You Get Your Results During Your Visit? in Visiting Mayo Clinic

I’ve been seeing several specialist at Rochester Mayo for past 3 yrs. In my
experience the first consultation determines what testing is needed. Mayo
does not repeat tests you’ve already had unless they’re poor quality or
old. It’s best to bring discs of any radiology tests or tissue slides, not
just the reports. Their physicians will actually evaluate the tests and
give a report. They will charge for that. My insurance has always
paid without problems. After your first consultation,you’ll be provided
with a plan of care. ie: schedule of all tests, appointments with other
specialist and a revisit with the first physician you saw. Typically the
initial physician will review the results with you at the end of all
testing. If you are referred to other specialists, they will review with
you the tests they ordered. Unfortunately, due to the volume of patients,
sometimes everything can’t be done within the expected time period, if
tests are added on, a return visit may be necessary or extend our stay.
Their system is most efficient at trying to get everything done at one
visit. I’ve had visits with everything completed, other times needed to
return and yet another finished ahead of schedule. The better prepared you
are with your medical records makes for more efficient visit. Majority of
patients are understanding in the necessity to return for further testing.
On my last visit, after a full week , my final test was completed late in
the afternoon. My physician actually was on vacation, but came in that day
to see me even though he knew results would take a few days. He didn’t want
me traveling there and going thru difficult tests without a face-face visit
with him. He called the following Tuesday and discussed results and
treatment. Also, there is no outpatient testing or office appts on
weekends. If you have questions that you forget to ask, they have a patient
portal. Sign up and you can contact any physician you’ve seen, see test
results, office visit summaries and request appts. Having been cared for
by top experts in their fields and the genuine empathy and friendliness of
all staff makes traveling to Mayo well worth the trip.