Three Affiliated Tribes Sanford insurance plan sends health care titans into a legal battle no audio

“The result of Sanford’s negligent and material misrepresentations is that Mayo has gone unpaid for more than two years for the health care goods and services it provided to patient C.G.,” according to the complaint filed Dec. 13.

In the complaint, it was stated C.G. was hospitalized at CHI St. Alexius in North Dakota and then transferred to Mayo Clinic for a transplant. The hospitalization lasted from Feb. 5 to March 29, 2022. Mayo claims Sanford failed to provide pertinent information regarding the Three Affiliated Tribes Tribal Health Plan it was administering. Sanford claims the tribal health plan was a “payor of last resort” and another insurance entity, Blue Cross Blue Shield, should have been billed first.

On Dec. 20, in a motion to dismiss, Sanford offered several reasons for ending the case, citing that Mayo failed to follow Medicaid Expansion procedure causing Blue Cross Blue Shield of North Dakota to deny Mayo’s request for reimbursement. Mayo must respond by Jan. 17.

Sanford Health, one of the largest health systems in the United States, is based in Sioux Falls, South Dakota. The organization includes 46 hospitals, 1,500 physicians and serves large rural areas near American Indian reservations.

Mayo Clinic-Mayo Hospital, based in Rochester, Minnesota, is the largest integrated, not-for-profit medical group practice in the world.

Two health behemoths fighting over who’s responsible for a Native patient’s medical bills gives the lawsuit a twist because typically, the Native patient gets stuck with paying costs denied by insurance or the Indian Health Service. A federal report released in December states Native community members “were almost twice as likely to have medical debt in collections on their credit records compared to the national average, and the average amount of debt in collections was about 33 percent higher than the national average.”

Native patients often have little control over where they receive medical services given the lack of Indian Health Service year-round primary care facilities and state Medicaid expansion.

“Analysis of complaints and reports from health care providers, Tribal officials, and other key

stakeholders indicates that problems with billing, reimbursement, and credit reporting are

common and pervasive for Native consumers,” according to the Consumer Financial Protection Bureau report. “People in Native communities face a confusing and complex approval process, especially for specialty or emergency care in non-IHS facilities. This often results in unexpected medical bills.”

Two bills are now before Congress to address high rate of medical debt for Native Americans and IHS billing processes.

Meanwhile, the Three Affiliated Tribes, also called the Mandan, Hidatsa and Arikara Nation, has taken steps to make health care more readily available for tribal citizens. Many tribes, such as MHA Nation, engage in Public Law 93-638 contracts, agreements between IHS and tribes under the Indian Self-Determination and Education Assistance Act. The 638 contracts allow tribes to manage federal programs, including health care.

In the exercise of tribal self-determination, the Three Affiliated Tribes has tried to improve health care for its citizens. It entered into a health insurance agreement with Boone Group Insurance. That plan drew complaints from those using it. In January 2021, a tribal citizen sought financial help from the TAT Tribal Business Council for medical bills. “Boone Insurance isn’t paying them,” according to TAT TBC minutes.

On Jan. 1, 2022, the tribe replaced Boone with the TAT Sanford Health Plan. The MHA website states benefits of the plan, “The MultiPlan’s nationwide network can also be used for urgent and emergent coverage while traveling. In addition, Mayo Clinic Hospital Rochester prior authorization is not needed for in-network benefits and the Substance Abuse Network is included for all eligible members in sober living.”

Four months after initiating the Sanford Health Plan, two Sanford representatives, Courtney Meyers and Jennie Nickles, made a presentation to the TAT Health and Human Services Committee. They discussed cost containment strategies and productive management.

In the Mayo complaint, plaintiffs contend that “Sanford led Mayo to believe, through its representations and actions, that patient C.G. was an insured of Sanford Health Plan and that it was the payor on claims for the health care goods and services provided.”

In doing so, Mayo alleges Sanford held itself as the primary insurer, verified eligibility and preauthorized all dates of service for the health care Mayo provided to the patient of the TAT tribal health plan. At one point, Sanford paid some of the patient’s medical bills. “Sanford alone had access to patient C.G.’s policy and TATTHP Plan,” according to the suit.