Letter sent to NM Public Regulation Commission

Commissioner Ben Lujan 14 January, 2008
NM Public Regulation Commission
1120 Paseo De Peralta
P.O. Box 1269
Santa Fe, NM 87504

Dear Commissioner Lujan,

I really hope you can help me resolve a Medical Insurance claim problem perplexing me (and possibly several dozen other local patients).

Over the past year, three separate doctors told me that a shoulder surgery could relieve some of the persistent head, neck and shoulder pain I was experiencing. I did my due-diligence; talked with Dr. Auge, a great local surgeon, who operated at both Espanola Hospital and Physicians Medical Center Hospital of Santa Fe, compared their estimated charges for the surgery and opted for that surgery at Physicians Medical Center (PMC) last June 20, 2007.
Prior to that surgery; the doctor’s office and hospital informed me that United Health Care (UHC) had approved the upcoming procedure(s). (Confirmation of that UHC approval including their negotiated surgery rate is attached)
I’m very thankful that the surgery and recovery went well and that the surgery significantly reduced some of my shoulder pain.

UHC has now paid the Anesthesiologist and the Surgeon for my surgery but rejected the hospital charges where they performed the surgery; as being “Out of Network”! Despite the prior approval & negotiated rate agreement with the hospital, UHC has now reneged on that agreement and dumped the hospital bill onto me! I understand that several other PMC patients may have received similar rejections for the UHC “approved” procedures. A common factor is that those patients may also be employees of Los Alamos National Laboratory. Those payment rejections by UHC, certainly have a damaging effect on the patients like me, who have paid premiums each month for health insurance and this must also present a damaging effect on a Not-For-Profit Santa Fe hospital. We’re already losing too many good medical providers, in New Mexico, without UHC unfairly stiffing a provider for services already approved and rendered.
I’ve asked UHC how they could pay for the surgeon but NOT where he did the surgery. They’ve told me that the hospital “was not in the network at the time of the surgery but it will be soon”. I was told that the hospital bill is now my responsibility.

Instead of bothering you; I suppose I could have just deluged UHC with my own appeal letters but even if that had worked, it would only satisfy MY billing problem but this may well be a larger, systemic problem with an insurance company that first approves and then arbitrarily rejects payment for those services after the surgery and this also possibly involves numerous other patients with similar payment problems from UHC.
It’s ironic that this week, in Santa Fe, the Legislature will begin discussing statewide healthcare for all residents. I’ve long paid for my own healthcare and now that company has opted only for SELECTIVE payments of my medical care!!

There’s a serious problem present when an out-of-state firm, which gladly accepts my insurance premiums, initially approves a surgical procedure and then after that procedure is performed they totally renege on the payment once the bill arrives. Obviously their actions could harm not only my financial situation, but hurt a local firm that acted upon the UHC pre-approval / payment agreement and quite possibly effects numerous other local patients in a similar manner.
I hope it’s just a coincidence that numerous Los Alamos employees may have been stiffed on the payment of their medical procedures which were provided by the very same Santa Fe hospital. I trust that I didn’t cause this problem myself by NOT going to a Los Alamos hospital for my surgical procedure, like some other patients told me.

I hope that you’ll have someone look into this problem, which may be common to numerous local patients of Physician’s Medical Center.
I’d welcome the opportunity to discuss this matter with your insurance investigators and share my limited information with them regarding this situation in an effort to clear up the problem for me and possibly dozens of other patients.

Thanks in advance Commissioner Lujan, for your assistance in clearing up this matter.

Cc: - Mr. Morris Chavez, Superintendent of Insurance
- Mr. Aaron Felicano, Chief, Investigations Bureau
- Ms. Diana Bonal, Health Product Bureau
- Mr. Ben Montoya, Insurance Fraud Bureau
- United Healthcare Insurance Co., Salt Lake City, UT