Mary Jo Oxford thought she was being responsible with her health insurance. She had a job, paid her monthly premiums and made sure she knew what was covered and what was not.
But when the Ruidoso resident suffered a heart attack, and an air-ambulance company transported her to Lubbock, she ended up with a bill for almost $60,000.
And when her insurance company paid the ambulance firm $20,000, the company sought her out for the balance. Through research she discovered there were two other ambulance carriers in New Mexico that would have accepted what her insurance paid.
But the firm that transported her “aggressively pursued collection,” she told lawmakers in Santa Fe on Friday. “That is their policy.”
Oxford’s experience is not unique for emergency patients who receive a surprise bill from a company or a specialty provider not under the umbrella of their insurance network. As more insurance companies try to control costs by tightening their patient offerings and networks, more doctors and services might be outside those contracts — especially in rural areas.
A bill that would protect consumers from these bills received its first hearing Friday before the House Health and Human Services Committee. The measure, HB 313, sponsored by Rep. Deborah Armstrong, D-Albuquerque, received a 4 to 3 do-pass recommendation, but it is meeting opposition from insurance companies, physician groups and hospitals.
An analysis of the bill indicates that half of the emergency visits in Southern New Mexico result in a surprise charge. That number is about 15 percent in Northern New Mexico.
The bill comes after a series of listening sessions by the Office of the Superintendent of Insurance, which had representatives travel the state to hear consumers discuss insurance coverage and the adequacy of hospitals and providers in their region.
“The OSI receives more complaints about surprise and balance billing than any other kind of complaint,” Paige Duhamel, health-care policy manager for the agency, told lawmakers.
Other states have enacted similar legislation that takes the patient out of these disputes, leaving the physician or provider to negotiate reimbursements with insurers. The New Mexico law would do that for emergency care, and establish an arbitration structure to help that along. It also calls for more transparency, patient disclosures and education about insurance networks and patient obligations.
“What we are trying to resolve with the legislation are the endless stories where the consumers are caught in the middle,” said Duhamel.
Consumer groups testified that many people who get these surprise bills don’t even realize that they may not need to pay them. “I came from the corporate world and if I knew two-thirds of the people who get a bill will pay it, then I would send the bill,” said Dick Mason of the League of Women Voters of New Mexico.
Barbara Webber of Health Action New Mexico said she is still paying thousands of dollars for an out-of-network hospitalist who cared for her husband. Rep. Gail Chasey, D-Albuquerque, said she was hit with a $900 bill that was unexpected.
“You get bills. Even if you’re billed incorrectly, you think you’re responsible,” said Nat Dean, a Santa Fe woman who survived a brain injury.
Oxford remembers being strapped into a stretcher as the air ambulance was set to take off and asked to sign paperwork about billing. “I’m in a gurney and on a plane and I’m handed a form,” she said. “As a consumer, I plead for you to protect us.”
But insurers and medical providers said the legislation needs more clarity as far as dispute resolution and fines. The proposal also goes further than other states and that might have implications for physician recruitment.
Providers recognize a problem, but with possible federal changes to the Affordable Care Act coming with the new Trump Administration, there is too much uncertainty in health care to impose more regulations, said a lobbyist for ABQ Health Partners, a physician-owned practice in Albuquerque.
The bill would not cover government insurance plans or self-insurance groups, which are regulated by the U.S. Department of Labor.
Republicans on the committee said the 32-page bill is too complicated to debate during the current session and should be rolled over so the Office of the Superintendent of Insurance can resolve some concerns.
“This is 32 pages of new material,” said Rep. Rebecca Dow, R-Truth or Consequences. “I agree there’s an issue but there’s a lot of discussion on whether the language is right.”
“In my opinion the bill needs some work,” added Rep. James G. Townsend, R-Artesia.
With Democrats in the majority, however, a motion to table the bill was defeated along partisan lines. It now goes to the House Judiciary Committee.
Contact Bruce Krasnow at (505) 986-3034 or [email protected].