ALBUQUERQUE, N.M. (KRQE) – A freak accident left a New Mexico woman fighting for her life. After what her family describes as a “miraculous” recovery, she found herself fighting a whole new battle.
On Special Assignment, KRQE News 13 looked into a problem that often times insurance can’t save patients from.
December 2015 in Alamogordo, one sweeping moment would change Samantha Hunt’s life.
“I was at a graduation party,” she recalled. “We were country dancing and the partner that I was dancing with went to flip me. [He] flipped me once, everything went great, went to flip me again, dropped me on my head.”
Winter weather kept her from being flown to the University of New Mexico Hospital in Albuquerque. So an ambulance rushed her to the nearest Level One Trauma Hospital for emergency surgery in El Paso, Texas.
“I was in a coma for two, almost two-and-a-half weeks, brain surgery, the whole works,” Samantha told KRQE News 13.
“To me it’s the worst call a parent could ever get,” said Samantha’s dad, Terry Riordan. ‘Your daughter’s hurt, out of town.'”
Terry jumped in the car to make the four hour drive from Albuquerque to El Paso. “Evidentally she ruptured a blood vessel inside her brain and it was bleeding and compressing her brain.”
Her family feared the worst.
“It just takes your heart away to see your daughter like that,” Terry said. “My fear was she wasn’t gonna survive. And I believe that if she hadn’t had the surgery within the hour, she would have died.”
But Samantha survived, and with intense physical therapy, she managed to get back on her feet. That is, until she started opening her mail.
“My first thought was ‘Ok it’s gotta be a mistake,’ maybe they just didn’t get my insurance,” said Samantha.
She opened a bill from the University Medical Center Hospital in El Paso for $95,000.
At the time, Samantha had insurance through New Mexico Health Connections. So why was her bill so high? That’s because the El Paso hospital was considered ‘out-of-network.’
Had she made it to UNMH that night, her insurance would’ve covered emergency care.
“I was in tears, because I was like ‘this can’t be right,'” Samantha recalled.
The bills kept coming, even a letter threatening to send her to a debt collector.
As it turns out Samantha was facing a problem others who are fully insured have also faced: Surprise or Balance billing.
Surprise or Balance Billing:
In proposed legislation, a ‘Surprise Bill’ is defined as a bill for an emergency medical, mental or behavioral health service or ambulance service provided to a covered person by a nonparticipating provider.
After inadvertently receiving care from an out-of-network provider, an insured person may receive a surprise bill, or the ‘balance’ of a medical bill that insurance did not pay.
“Surprise billing or balance billing certainly is a nationwide problem that many health plans, many provider organizations, emergency departments are dealing with today,” said Dr. Mark Epstein, Chief Medical Officer for True Health New Mexico, which provides medical management to New Mexico Health Connections.
He said especially after an emergency service, patients can find themselves victims of balance billing.
Since Samantha had a head injury in need of immediate surgery, she wasn’t in a position to pick a hospital in network. Usually, Dr. Epstein said, hospitals and providers can work out a payment agreement, but it’s not always easy.
Under the Affordable Care Act, Dr. Epstein said, “We must pay usual and customary fees for those services as if they were in network. That’s what a health insurance company is obligated to do.”
The problem is often times the payer and provider can’t agree on what is “usual and customary.”
“There’s today, I would say a gap in bringing those two entities to the table and saying ‘resolve this and please leave the patient out of it,'” said Epstein.
That’s where the Office of The Superintendent of Insurance, or OSI, can come in.
Insurance Superintendent on Surprise Billing:
“Ever since the Medicaid expansion in the state of New Mexico, we’ve had 350,000 more people insured under health plans,” said John Franchini, Superintendent of Insurance.
Franchini said with more people insured, his office is overwhelmed trying to help resolve balance billing problems.
“Our department has not been prepared for the large number of complaints that have occurred,” said Franchini.
There were 368 complaints just last year, he said. His office along with the University of New Mexico Center for Health Policy conducted a study that surveyed 554 privately insured New Mexicans. Read the complete study >>
The study found 1 in every 5 policy holders in the state had a surprise bill, and 1 in 2 people who made a trip to an emergency room received a surprise bill.
Currently, there are protections for consumers in New Mexico. An insured person who obtains emergency care from out-of-network facilities is only supposed to be responsible for paying in-network charges; but it’s not always so clear-cut.
“We know that this is a problem and we need to help fight this,” said Franchini. “We need to find a way to allow the doctors to get what they feel is necessary and yet allow the insurance companies to have a fair break in the cost so that the policy holder doesn’t have to pay more money.”
He plans to introduce new legislation next year to try and get all players on the same page when it comes to patient billing to avoid surprises. This year his office is asking for feedback on the bill. Read the proposed legislation >>
“Advocates, insurance companies, medical providers, hospitals, they all need to be together and we need to solve this together for now,” he added.
“Where challenges arise, is there’s not one regulatory body that oversees both the hospitals as well as the insurance companies,” Dr. Epstein said. He points out that the OSI has oversight jurisdiction over insurance companies but not over hospitals or emergency departments.
For now, there is recourse for victims of balance billing. First, you can file a complaint with your insurance company. If it isn’t worked out you can call the OSI.
But Samantha and her dad did all of that.
“Can you tell me why it has taken so long?” KRQE News 13 asked Franchini.
“From April to September we lost two of our staff. We only had one staff person handling managed health care claims,” Franchini replied.
He said his office should have had a public hearing in Samantha’s case. “The request for the hearing got lost upstairs in our legal department,” Franchini added. “It was just a pure accident and I apologize. It was our mistake.”
Since KRQE News 13 started asking questions, Franchini called Samantha’s dad directly and got involved in her case.
“I didn’t seem to be getting anywhere until I called you,” Terry told KRQE News 13.
Samantha’s dad quit his job as a dentist, and made it his full-time job to try and help his daughter since the accident.
Now more than two years after the accident, Terry got the message he’d been waiting for. He was notified via email last week that New Mexico Health Connections settled the bill with El Paso for an undisclosed sum. Samantha’s account was now at a “zero balance.”
But fighting a balance bill in the wake of almost losing his only child at just 30-years-old was the last thing Terry wanted to deal with.
Now he can focus on the strides his daughter has made. “It’s a miracle,” Terry said.
Samantha has since gone back to work, and got married in October. Her dad was there with her to celebrate the big day.
“I’m just thankful that she’s here, that’s all,” he added. “We’ll get through the other stuff.”
Public comments on the proposed legislation may be submitted in writing no later than March 15, 2018 to the OSI Santa Fe office or via email to: OSI@state.nm.us