Rochester, Minn.-based Mayo Clinic said its recent decision to clamp down on out-of-network patient appointments is a result of capacity issues, not a reimbursement quarrel, the Post Bulletin reported Feb. 15.
The provider began to disallow out-of-network Medicare Advantage beneficiaries to schedule appointments over the winter — a move it's beginning to be more stringent on. Mayo Clinic stated that the decision is due to limited space for patients whose health plans have the clinic in their networks.
"Mayo simply does not have enough capacity to serve an ever-increasing number of patients," a spokesperson told the Post Bulletin. "Mayo needs to be good stewards with our contracted plans. This is what drove our decision to enforce our policy consistently."
The spokesperson confirmed the policy to prioritize patients of contracted plans extends to all types of coverage and across all payers. However, medical need is the top criteria for scheduling an appointment.
"In situations where medical need does not apply and to ensure appointments remain available for our Mayo Clinic patients, we no longer schedule routine visits for those whose coverage does not include Mayo Clinic," the Mayo Clinic spokesperson said. "Continuity of care and relationships with existing local and regional patients won’t be compromised."
Two factors pointed to UnitedHealthcare as a potential reason for the change; the payer is currently negotiating to bring Mayo Clinic into its network and its Medicare Advantage members make up the largest portion of out-of-network patients frequenting the provider.
However, Mayo Clinic told the Post Bulletin that between 2019 and 2021, non-contract Medicare Advantage appointments rose from 6,621 to 10,260, up 55 percent. In Minnesota alone, the appointments were up 95 percent.
The primary reason non-contract Medicare Advantage appointments are rising is because of federal surprise billing guidance that went into effect in 2022. Now, patients visiting an out-of-network facility must be charged the going rate for visiting an in-network facility.