The Santa Fe New Mexican Bruce Krasnow column

April 28--The downside for the millions of people who have newly purchased health insurance under the Affordable Care Act is that those patients now have to deal with health insurance companies.

A great case study might be the new medical clinics that have opened in Santa Fe this month -- sparkling new facilities operated by Presbyterian Healthcare Services on St. Michael's Drive and Christus St. Vincent Regional Medical Center, across from the Wal-Mart Supercenter near Interstate 25.

With expanded specialty offerings and physicians, there should be more choices for those seeking care. For the most part that is the case, as both clinics have in-network provider contracts with the largest insurance companies in New Mexico, including Medicaid.

But it can get complicated.

Christus spokesman Arturo Delgado said Christus has in-network contracts in place with Medicaid, Medicare, United Healthcare, Blue Cross Blue Shield, Cigna and Presbyterian.

"The only exception is that Presbyterian has refused to credential our new primary care providers at our new south-side health center. Our pediatric care providers are credentialed with Presbyterian at the south-side clinic, just not the primary care providers [for adults and seniors]," he said.

"So patients with Presbyterian insurance can see our providers at all our other facilities. The only exception being that they can't see the new providers at the new clinic."

And the Presbyterian facility also has contracts with most major providers -- but there are exceptions for those with Blue Cross Blue Shield, according to spokeswoman Kerri Dufault. And "we are always in discussion with payers, so this list could change," she added.

About as clear as mud, right?

The important takeaway is that patients need to speak up and ask questions. Then they need to ask more questions and advocate for themselves when necessary. That's hard enough for those of us with a college degree, let alone the thousands who are newly insured and have never had the honor of dealing with the health insurance bureaucracy.

Even for those who do ask questions or appeal, the information given to consumers can be wrong. My wife recently appealed a charge with a New Mexico carrier as her benefit booklet stated there was no copay for a particular service.

The head of the appeals panel told her the booklet was incorrect.

And those trying to retire in New Mexico with out-of-state insurance -- even it if it is Blue Cross Blue Shield -- can have an especially hard time.

One reader wrote to me about the frustrations of her husband, a retiree from the University of Michigan, who was told a Presbyterian provider was in-network, but that turned out not to be the case.

"Before making this appointment, we went to the BCBSNM and BCBS national website. ... The Web pages on both of these sites, showed the provider was in-network. Yet the claims processing department at BCBSNM says there's no contract.

"How is is possible for the website to show a provider is in-network and the claims department to say there is no contract?"

She continued, "Every place else we lived, no matter who the insurer, if a provider was in-network, they were not allowed to bill for anything other than the office visit copay required by the insurer."

And is it not enough that sick and struggling patients have to deal with copays and deductibles: Companies have now embraced the concept of "co-insurance."

In theory, the idea makes sense when the marketplace wants to encourage patients to shop and compare prices for elective procedures such as an MRI -- which can vary in cost from $700 to $1,300 -- or certain elective screenings and lab tests. But co-insurance for mandatory emergency room services where there is really no choice on who provides the care or if it's even necessary.

That's just a ripoff.

All these changes means patients need to be extra vigilant and ask a lot of questions about services before they are provided, and continue to ask when they receive payment statements.

But more people with health insurance also means the state, human resources offices, trade groups, unions and others who oversee benefits need to up their game and make sure consumers have the support so they only pay for services that are necessary and fairly priced.

Or we can just blow the whole system up and start over.

----Many readers have inquired about a possible Costco location in Santa Fe since the company first met with the city of Santa Fe Planning Department about a possible site at Las Soleras.

The company even hired an engineering study to undertake a preliminary traffic analysis. Since then, two developers have said that proposed location was not large enough to accommodate the needs of Costco.

Likewise, the new Village Plaza project along N.M. 599 is geared toward smaller retail operations and does not have the capacity to accommodate Costco. As far as we know, the company is no longer looking in Santa Fe for expansion.

Contact Bruce Krasnow at [email protected].

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