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Sorting through a health coverage mess

ALBUQUERQUE, N.M. — It is full-disclosure time.

Last week I reported that the University of New Mexico says Presbyterian Health Plan has been rejecting a lot of claims for treatment by specialists at UNM.

Presbyterian told its members in October that it would no longer include UNM primary care providers in its network of providers. UNM Hospital CEO Steve McKernan said UNM understood that its specialty services, including its cancer center and specialty clinics, would still be paid for service to Presbyterian plan members if UNM got prior authorization to provide treatment – regardless of whether those services were available in the Presbyterian network.

Not so, said Presbyterian Health Plan President Lisa Lujan. In the health plan’s reading, the letter of agreement the parties signed in October in lieu of a contract, which is still being negotiated, Presbyterian said it would pay claims for those specialties that are available only from UNM.


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That would include things like burn care, stroke care and some pediatric services. In most cases, if Presbyterian can provide the care through its own medical group or through another practice with which it contracts other than UNM, a claim for treatment at UNM would be denied. Among the exceptions are “complicated” cases or cases that are in “active” treatment at UNM. McKernan anticipates disagreements with Presbyterian over what “complicated” and “active” mean.

Here’s the full disclosure: That is precisely what happened to a family member of mine. Her claim for follow-up care for cancer surgery at UNM was denied by Presbyterian. She was informed she needed to find a cancer doctor in the Presbyterian Medical Group or with a cancer specialist approved by the plan.

I was shocked. The story I wrote about the UNM/Presbyterian difficulties in October reflected the UNM understanding. Since no one from Presbyterian called me at the time to correct the story, I assumed it was accurate. Now I’m worried that some readers were pursuing care at UNM based on the story the Journal published only to discover they would have to pay thousands of dollars out of their own pockets.

Presbyterian didn’t make its coverage plans all that clear last year. Lujan said the company did not contact UNM specialty care patients who hadn’t been seen at UNM for “several months” to let them know of the change, though it did contact primary care patients.

Presbyterian also sent what seems to me a vaguely worded letter to employers, including mine, in October, but I only saw the letter last week when I asked for it.

The letter tells employers about the change in primary care coverage, then says, “UNM also provides many specialty services, particularly in pediatrics, that are not available anywhere else in New Mexico. UNM will continue to offer these services as an in-network provider to our health plan members. Services will be prior authorized as needed.”

Had I seen the letter last year, I’m not sure I would have performed the mental gymnastics the plan seems to have expected – that by saying it is going to pay for unique services I am to infer that it is not paying for non-unique services.

This includes X-rays, CT scans and other diagnostic procedures, by the way.


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The way things are working out, according to McKernan, UNM is having trouble getting timely prior authorization from Presbyterian. Rather than make patients wait for care, McKernan said, UNM was providing care in anticipation of getting authorization. He said UNM has stopped doing that.

My personal agita aside, there is a broader point to be made here.

First, this is hardly the only health plan difficulty out there. I get calls all the time from people whose coverages seem to change without warning, rhyme or reason. I hear from providers whose payments are unilaterally changed by one health plan or another.

Insurance products, which are contracts between insurers and consumers, are enormously complicated, and some confusion is inevitable in the employer-centric, for-profit health care finance system we practice in the United States. There are also times when insurers are incompetent or worse.

Second, thanks to Obamacare, we are throwing thousands, perhaps millions of people into this mess who have never had insurance and may have very little experience as health care consumers.

We have speculated that in New Mexico if we could just get an insurance card into everyone’s pocket we would lower costs and improve quality of care and quality of life. About 20 percent of our residents were uninsured before Obamacare, which includes, for the first time, Medicaid coverage for healthy, working-age, low-income adults in states, like New Mexico, that accept new federal funding. A recent survey shows our uninsured rate is down to 15 percent.

That can’t hurt, but there is more to health than a payment mechanism. Now that there is a reasonable hope that most people will be covered, we are going to discover what else is wrong with our health care system. Not being able to understand or count on coverage from the provider you want will certainly come up.

Third, health insurance is fungible, except when it comes to the provider network.

Locally, all the health plans tout their wonderful services, their mechanisms for improving population health and their affordable premiums. Their marketing pitches are virtually identical.

In reality, many consumers have no choice in the matter because their employers make the choice for them. Even when there is a choice, the local market is such that you choose your insurance company based entirely on whether your doctor accepts the insurance. Beyond that, there is no other obvious value to choosing one insurer over another.

An insurance plan that is easy to use, easy to understand, consistent and fair would stand out in this or any other market.

UpFront is a daily front-page news and opinion column. Comment directly to Winthrop Quigley at 823-3896 or Go to to submit a letter to the editor.