The patient stayed at the Mayo Clinic in Rochester for 52 days in 2022.
ROCHESTER, Minn. — The Mayo Clinic in Rochester is suing health insurer Sanford Health Plan for failing to pay the claims of a patient who stayed at the Mayo Clinic for 52 days in 2022.
In the lawsuit, the Mayo Clinic alleges the patient was transferred from North Dakota to Rochester to receive a higher level of care. Their primary insurance was listed as Sanford, with Blue Cross Blue Shield North Dakota Medicaid as secondary.
Days after the patient was in Rochester, Sanford “approved and authorized every day for health care goods and services,” Mayo states in the lawsuit, adding that Sanford paid several submitted claims.
“At no time during the period that Patient CG received any inpatient health care goods and services at Mayo, nor in any of the conversations or correspondence between Mayo and Sanford regarding Patient CG’s care and approvals therefor- “Did Sanford not state that Patient CG was in fact insured by a tribal plan that Sanford administered,” the suit states.
According to Mayo, Sanford contacted them after the patient was discharged to tell them the real payer was a tribal plan, claiming to be a “payer of last resort.” Next, Sanford asked Mayo to refund payments made on submitted claims, adding that Mayo should bill Blue Cross Blue Shield ND as the primary insurer. “Mayo repaid these payments in good faith,” the complaint states.
BCBS ND denied the patient’s claims in this case due to a lack of prior authorization.
“Mayo allegedly did not request pre-authorization from BCBS ND at the time of Patient CG’s admission because she was led to believe that Sanford was the principal,” court documents state, “and Sanford confirmed this fact by pre-authorizing all service dates and paying multiple claims submitted to Mayo for those dates.
The Mayo Clinic contends that Sanford’s “negligent and material misrepresentations” left the hospital system unpaid for more than two years in the amount of $739,956.20.
Sanford said in a statement to KARE 11 “Sanford Health Plan does not comment on active or pending litigation to protect the privacy of those involved and out of respect for the legal process.”