A woman in a small New Mexico community was pregnant and went into labor prematurely. She went to the right hospital — that is, the one covered by her health insurance plan. She gave birth to premature triplets. Specialists were called in. Two of the babies could not be saved.
Several months later, she and her husband were confronted with more than $3 million in medical bills.
Heather Widler of the New Mexico Office of the Superintendent of Insurance (OSI) explained what happened. The hospital had to call the specialists for this urgent situation. The specialists were not contracted with the health plan that covered this family. They were “out of network.”So they billed the patient directly.
This kind of complication happens so often in the topsy-turvy world of today’s health insurance system that it has a name: surprise billing.
According to a Consumer Reports study cited by OSI, 30 percent of privately insured Americans have received a surprise medical bill. Consumers pay an estimated $1 billion annually in these unexpected billing charges.
Most consumers don’t know what to do, said Widler, when billing issues like this arise. Some pay the bill without asking any questions or raising the issue. Sometimes the paperwork is so confusing to consumers that they send a check when the notice they received was not even a bill.
OSI wants you to know that help is available from OSI’s Managed Health Care Bureau. You can call the bureau at 1-855-427-5674.
In the case described above, OSI helped untangle the billing complications so the family owed only their contracted annual maximum.
In cases like this it’s also critical, said Widler, to work with the insurer, the hospital and the specialists so that no party ends up being a big loser. Our institutions cannot afford to absorb big losses, she said.
OSI is the new state agency created when the former Department of Insurance was separated from the Public Regulation Commission by a constitutional amendment approved by the voters in 2012. Now that it is separated from the politically charged PRC, OSI is moving aggressively to develop a number of consumer protection initiatives., including this one.
One concern is reaching the people who have the greatest need for assistance. OSI has held several public meetings around the state, but that’s not nearly enough to reach people who might be receiving surprise bills.
(Disclosure: I am a volunteer member of the Insurance Fraud Policy Advisory Group, which works with OSI.)
Here’s my request: if you are a community leader, or if you are in the health care field and in contact with patients, keep this information in mind and share it with those who might need it.
Nationally, the Affordable Care Act has reduced some of the strain of surprise billing by requiring that in an emergency, the bill from the hospital itself must be handled as if in-network, even if the patient went to the “wrong” hospital.
A few states have passed legislation protecting consumers from surprise bills. Others are considering legislation. While OSI’s help can protect some consumers from some excessive bills, it does not have the authority to fix every problem. And we have to remember that our state is short of doctors and our rural hospitals are financially distressed, so we can’t simply force them to absorb these costs.
This surprise billing issue is just one aspect of much bigger problem: our irrational, confusing and overly expensive health care system. Whether you think the Affordable Care Act made the system better or worse, our nation desperately needs to reach a consensus on how to fix it. Until then, New Mexico should follow the lead of other states and seriously consider a law to protect both the consumers and the providers.
Triple Spaced Again, © New Mexico News Services 2016