The New Mexico Office of the Superintendent of Insurance (OSI), in partnership with the Robert Wood Johnson Foundation at the University of New Mexico (RWJF/UNM) recently released a study of New Mexicans’ experiences with surprise billing from medical providers.

The OSI asked privately insured New Mexicans about their experiences obtaining health care from providers inside and outside of their insurance plan’s network. The survey focused on consumers who experienced a medical emergency or major surgery and those who have received surprise bills.

About 554 responses echoed national trends around balance billing:

  • Approximately 20% of privately insured respondents received a surprise medical bill.
  • Of those residents who had had surgery (36%) or an ER visit, (55%) had received a surprise bill.
  • 46% of respondents who had received a surprise bill said it came from a doctor they did not expect to get a bill from.
  • 26% indicated that they received separate bills from multiple providers.
  • 28% indicated that they were charged an out-of-network rate when they thought the provider was in-network.

The study echoes findings from across the United States, where legislators are in varying stages of attempting to pass federal balance billing legislation to keep consumers out of the middle of payment disputes that might be resolved directly between health care providers and insurance companies. New Mexico is unique in that it already has state protections for consumers who receive surprise medical bills for out-of-network emergency care. Consumers who obtain emergency care at out-of-network facilities or from out-of-network doctors at in-network facilities are only responsible for paying in-network charges. Health insurance carriers and providers are required to negotiate payment of the remainder of the bill without involving the consumer.

The full NM Surprise Medical Billing Study report can be found here.

insideARM Perspective

insideARM covered this topic several times in 2017:

  • As of April, five states had enacted laws to protect against or prohibit balance billing practices, including Illinois, California, Connecticut, Florida and New York. Nine others had pending legislation.
  • In October insideARM reported that six states had comprehensive balance billing protection, while 15 states had limited protections, and 29 states plus the District of Columbia had no protections at all. New Mexico is one of the states with limited protections.
  • Also in October, the billing practices of emergency rooms run by EmCare (Envision Healthcare and its subsidiary EmCare Holdings, Inc.) came under the microscope. Following a rash of consumer complaints and public reports supporting allegations that they gouged consumers and pressured doctors to order expensive, unneeded tests, Sen. Claire McCaskill (D-MO) sent a strongly-worded letter to Christopher Holden, President and CEO of Envision, looking for answers. (As of today, January 23, 2018, insideARM has not been able to confirm whether answers have been provided.)

Without a clear national standard for balance bills, consumers remain at risk and providers face significant administrative hassle. Those that offer outsourced business office or collection functions to healthcare providers should be fully educated on the laws related to balance billing, and a range of patient financing options.


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