One of the world’s most prestigious healthcare institutions is being sued by an employee who accuses the institution and its health insurance provider 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 claims that Mayo Clinic, one of the world’s top five hospitals, and Medica, the company that manages its self-insured health plan, intentionally prevented in-network services and providers from appearing in its online search tool.
When there were apparently no in-network providers available, the employee in the lawsuit said he had to use an out-of-network provider, which cost him more than $1,000.
Now, the employee is asking for a refund of the money he claims he spent on care and that should have been reimbursed.
Pictured: Saint May Hospital, part of Mayo Clinic, in Rochester, Minnesota
The Mayo Clinic is widely considered one of the best hospitals in the U.S. and consistently ranks among the top five medical institutions in the world.
The main facility is located in Rochester, Minnesota, but there are several locations throughout the United States, plus 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 health giant has 16 hospitals and 50 specialized clinics.
According to the hospital’s most recent financial reports, in 2023, it had revenue of $18 billion on revenue of $1.1 billion. Mayo Clinic is a nonprofit healthcare institution, meaning its revenue is invested in the community, its staff, and cutting-edge research and services.
Mayo Clinic offers employees self-insured plans, meaning the employer itself collects enrollees’ premiums and fees, as opposed to a separate health insurance company.
This means that the company is responsible for paying medical claims for employees and their dependents.
In it class action lawsuitFiled in U.S. District Court on April 2, the employee said he was looking for a psychiatrist after his son suffered a “mental health crisis” in 2019.
The employee visited the insurance website and searched for children’s mental health care providers within a 50-mile radius of his home in Scottsdale, Arizona.
The search returned no results for in-network doctors who would be covered by insurance.
They decided to see a doctor who was not covered by Mayo Clinic health insurance and sent their bill to Medica for reimbursement. Her claim was denied, the lawsuit claims, due to the fact that there were several in-network providers available within a 25-mile radius.
Medica did not explain how these providers were found and why they did not appear in the employee’s provider portal, according to the complaint.
The employee attempted several times to appeal Medica’s decision not to reimburse them, but each time they were denied.
The lawsuit alleges: ‘Mayo and Medica are involved in an illegal “kickback” scheme in which Mayo and Medica take funds given to them by members of the plan and illegally retain them for their own benefit, forcing (individuals) to pay twice for the same thing. services.’
The complaint called the practices “acts of mail and wire fraud, racketeering” and alleged violations of the Employee Retirement Income Security Act of 1974 and the Racketeer Influenced and Corrupt Organizations Act (RICO), which typically is considered in criminal proceedings involving corrupt organizations. 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 has been in the spotlight. Current and former employees who are not involved in the ongoing lawsuit told the Minnesota Reformer in October they sought out-of-network providers for essential care or avoided medical care for fear of what it could cost them.
One worker said he had to reduce counseling about his daughters’ mental health conditions and avoided seeing a physical therapist for his back pain, despite paying $11,000 a year for health care coverage.
Another employee told the Reformer she was “terrified” of having to go to the hospital after paying $1,200 for a routine physical and blood exam in January 2023, even though she said her state insurance benefits should cover half.
And one former employee is still paying off $10,000 of medical debt she acquired during her employment at Mayo.
The former employee told the Reformer that she switched to her husband’s health plan despite a $7,000 deductible because she had in-network doctors she could access.
She said: “I felt bitter after that experience… In theory, the world’s largest hospital network is supposed to take care of its employees.”
Another Mayo Clinic employee 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 her to receive subpar care at a “super shady” clinic after Medica said the first place she went was out of network.
She told the Reformer that she still had to pay more than $300 and had complications after receiving the stitches.
In a statement to DailyMail.com, Medica said: “As administrator of Mayo’s employee health plan, Medica is committed to helping Mayo employees understand their in-network care options and partnering with Mayo to provide their Give employees the tools and resources to help them understand their plan.
“We will respond to the lawsuit, but we cannot comment further on the lawsuit at this time.”
In a separate statement to 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 not be commenting further at this time.
