When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
You’re protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Balance billing of a patient by the nonparticipating (out-of-network provider is prohibited unless agreed to in writing by the patient. (CS/SB 346)
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have these protections:
- You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
- Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, contact: 855-427-5674 in New Mexico or the federal phone number for information and complaints is: 1-800-985-3059
Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
Visit osi.state.nm.us for more information about your rights under New Mexico law.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.
Non-Retaliation/Whistleblower Protection Policy
This policy reflects our commitment to ensuring that compliance and regulatory concerns and comments are properly addressed and that individuals bringing issues to our attention are protected from retaliation. You can either read through the policy below or download the document with the following link.
Signed Policy (PDF) – Download the signed policy document
Purpose
This policy is intended to encourage and enable employees and other stakeholders to report concerns regarding actual or suspected unethical, illegal, or fraudulent conduct within Miners Colfax Medical Center (MCMC), without fear of retaliation or intimidation. It establishes procedures for handling reports and ensures protection for whistleblowers; this policy includes protections specific to HB 586 for health care employees.
Applicability
This policy applies to all employees, Board of Trustees, contractors, consultants, volunteers, and any third party (e.g., vendors, suppliers) who interact with MCMC.
Effective Date
Immediately upon approval.
Definitions
- Entity – means hospitals, management service organizations and health care provider organizations that are owned or affiliated with health insurers
- Unlawful or Improper Act: Is defined as a practice, procedure, action or failure to act on the part of an entity that: (1) that violates a federal law or regulation, a state law or administrative rule or law (2) violates the Health Care Consolidation Oversight Act or the authority’s or attorney general’s ability to exercise authority pursuant to that act or (3) constitutes gross mismanagement, malfeasance, a waste of funds, an abuse of authority or a substantial and specific danger to the public or patients.
- Good Faith – Protected Disclosure: A protected disclosure is any good-faith communication, that a reasonable basis exists in fact as evidenced by the facts available, made to the state, the Attorney General’s Office, the Health Care Authority or other relevant agency.
- Illegal Order: An illegal order is any directive to violate or assist in violating an applicable federal, state, or local law, rule or regulation.
- Whistleblower: A whistleblower is any individual, health care provider, officer, employee, contractor subcontractor or authorized agent of an entity who reveals information about an unlawful or improper act by the entity, including but not limited to fraud, bribery, or corruption, financial misconduct or misrepresentation, breach of legal or regulatory obligations, unsafe work practices or environmental violations, harassment, discrimination, or abuse, any attempt to conceal such misconduct, violations of federal and state laws, rules and regulations.
- Retaliatory Action means any discriminatory or adverse action taken by an employer against a whistleblower, including termination, discharge, demotion, suspension, denying overtime or promotion, reducing pay or hours, harassment or limitation on access to healthcare services.
- Compliance Officer (CO).: The person designated by Miners Colfax Medical Center (MCMC) as the official with primary responsibility to receive reports of allegations of suspected improper activities
- Remedies for Whistleblowers: If an employee faces retaliation, they can sue for damages, including reinstatement to their previous position, double back pay and reimbursement for litigation and attorney fees.
Policy
MCMC strictly prohibits retaliation/intimidation in any form, and shall not take any retaliatory action against a public employee/whistleblower who:
- Discloses to the authority, the attorney general, the office or any other state, local or federal governmental body information about an action or a failure to act that the whistleblower believed in good-faith constitutes an unlawful or improper act;
- Provides information to, or testifies before, a public body as part of an investigation, hearing or inquiry into an unlawful or improper act; or
- Objects to or refuses to participate in an activity, policy or practice that constitutes an unlawful or improper act.
Any act of retaliation should be reported immediately and will result in disciplinary action, up to and including termination.
Reporting Allegations of Suspected Improper Activities:
- Any person may report allegations of suspected improper activities/concerns through any of the following channels:
- Direct supervisor or manager
- Designated Compliance via phone 575-445-7861, in person or in writing
- Anonymous reporting via the Compliance Hotline at 575-445-7799
- HR Department Manager
Report Information
Reports should include as much detail as possible to facilitate a proper investigation. Reports of allegations of suspected improper activities are encouraged to be made in writing. Such reports should be factual rather than speculative and contain as much specific information as possible to allow for proper assessment of the nature, extent and urgency of preliminary investigative procedures.
Confidentiality
All disclosures will be handled in a confidential and sensitive manner. The identity of the whistleblower will be protected to the fullest extent possible consistent with the need to conduct a thorough investigation.
Investigation and Follow-up
All reports will be taken seriously and investigated promptly. Investigations will be conducted objectively and independently, and appropriate corrective action will be taken, if warranted. Investigations will be performed by the Compliance Officer or the appropriately determined staff. Upon conclusion of the investigation, the Compliance Officer or investigating staff will make a report and recommendation for discipline, when appropriate, to the Compliance Committee or appropriate personnel, for conference on the discipline to be imposed.
The whistleblower may be informed of the outcome to the extent permissible and appropriate.
Possible sanctions imposed on any individual found to have intimidated and/or retaliated against another employee include, but are not limited to, termination of employment.
False Allegations
Intentionally making false allegations is a serious offense and may result in disciplinary action. However, individuals who report concerns in good faith, even if not substantiated, will not face discipline.
Communication and Training
This policy will be communicated to all personnel, contractor or other agent of the facility, electronically or in writing and will be incorporated into onboarding and regular compliance training programs. This policy will be published on the facility website displayed in the hospital.
Review and Amendments
This policy will be reviewed annually and updated as needed to ensure effectiveness and compliance with applicable laws and regulations.
References
New Mexico Health Care Whistleblower Protection Act – part of House Bill 586; Health Care Consolidation Oversight Act, Section 24A-9-12 NMSA 1978; U.S. Department of Labor Whistleblower Protections; MCMC Code of Conduct