Santa Fe New Mexican Article

(This is from the New paper March 14 2008)
Insurance firm to pay disputed hospital claims

Anne Constable The New Mexican

3/13/2008 - 3/14/08
Los Alamos National Laboratory employees learned Thursday that United Healthcare will pay for services at Physicians Medical Center in Santa Fe after all. The insurance company had declined claims filed last year on the grounds that the hospital, located on Rodeo Park Drive East, was not in its network. Employees and some retirees who are insured through United Healthcare appealed, saying that they received written statements from PMC saying it would honor their in-network benefits. Later the hospital told them they were financially responsible for the bills. The total claims are estimated at $450,000. Rob Vitek, a systems engineer at the lab, said Thursday, "This is good news for LANL employees." For Steve Rivera, another lab employee, news of the settlement "was a relief for me, my family, for everyone." Rivera, who had knee surgery at PMC, said he was happy that "the lab stood up for us." Cheryl Randolph, a spokeswoman for United Healthcare, confirmed that the insurance company had reached an agreement with Physicians Medical Center. All claims going back to April 25, 2007, will be reprocessed as if the hospital was in the company's network. "We certainly apologize for any confusion. We're glad we were able to work out an agreement," she said. According to Randolph, the hospital should not have told patients that their insurance would be accepted. Although United Healthcare was negotiating with the hospital, "somebody may have jumped the gun," she said. PMC officially became an in-network facility under the lab's insurance plan on Feb. 11. More than 30 people attended Thursday's meeting in Los Alamos convened by the lab's human resources director, Ben Glover. Vitek said a number of retirees, who are insured by United Healthcare, were present. Lloyd Scarrow stepped down as head of the hospital late last week. A spokeswoman from National Surgical Hospitals, a Chicago chain that is part owner of PMC, declined to give a reason. Many of the 2007 claims involved procedures by orthopedist Dr. Wayne Auge, a part-owner of the hospital. At the time, he was a member of United Healthcare's network and the insurance company paid his fees. But Randolph said that Auge violated his contract by operating on patients at PMC when it was not in the network. He was suspended from the network as of Oct. 29. Contact Anne Constable at 986-3022 or aconstable@sfnewmexican.com.