New Mexico IDR Arbitration For Medical Revenue Recovery

New Mexico Surprise Billing Law (SBL)

The New Mexico Surprise Billing Law (SBL) became effective on January 1, 2020, and is codified under New Mexico Statutes Annotated Section 59A-57A-1 et seq. (1978) and 13.10.16 and 13.10.33 NMAC. This law establishes standards for reimbursement and dispute resolution for out-of-network (OON) services provided in specific scenarios.

Key Provisions of the New Mexico SBL

1. Reimbursement Standard:
   • Payment must meet or exceed the 60th percentile of the allowed commercial reimbursement rate in the geographic area for the 2017 plan year, based on a state-approved third-party benchmarking database.
   • Payments cannot be less than 150% of the 2017 Medicare rate.
2. Dispute Resolution Timeline:
   • An arbitration process is available to resolve payment disputes.
   • The arbitration process has a 90-day timeline for resolution (13.10.16 NMAC).

Scope of Application

The New Mexico SBL applies to:

• Emergency Care:
  • Provided by nonparticipating providers.
• Nonemergency Services:
  • Rendered by nonparticipating providers at participating facilities under the following circumstances:
    • When participating providers are unavailable.
    • When nonparticipating providers deliver unforeseen services.
    • When services are provided without the patient's specific consent for the nonparticipating provider.

Insurance Plans Covered

The law governs OON reimbursement for the following types of plans:

1. Group health coverage under the Health Care Purchasing Act.
2. Individual health insurance policies, health benefits plans, and certificates of insurance under Chapter 59A, Article 22 NMSA 1978.
3. Multiple-employer welfare arrangements.
4. Group and blanket health insurance policies under Chapter 59A, Article 23 NMSA 1978.
5. Health Maintenance Organization (HMO) contracts under the Health Maintenance Organization Law.
6. Nonprofit health benefits plans under the Nonprofit Health Care Plan Law.

State and Federal Coordination

1. Specified State Laws:
   • Section 59A-57A-1 et seq. NMSA 1978 and 13.10.33 NMAC govern OON reimbursement for most emergency and nonemergency services in New Mexico.
2. Federal Independent Dispute Resolution (IDR):
   • The federal IDR process applies to:
     • Items and services not covered by New Mexico’s SBL.
     • Nonparticipating emergency facilities.
     • Nonparticipating providers of air ambulance services.
   • Federal oversight is guided by sections 2799A-1(c) and 2799A-2(b) of the Public Health Service (PHS) Act and 45 CFR 149.510 and 149.520.
3. Enforcement:
   • The Office of the Superintendent of Insurance (OSI) enforces dispute outcomes for cases under both state and federal jurisdiction.

CMS Clarifications

In a letter from CMS to the Governor of New Mexico (December 22, 2022), the following points were highlighted:

1. No All-Payer Model Agreement:
   • New Mexico does not have an All-Payer Model Agreement to determine OON rates.
2. State-Specific Provisions:
   • New Mexico’s SBL applies to emergency and certain nonemergency care scenarios.
3. Federal Oversight:
   • Federal IDR processes are applicable to services and providers not covered under New Mexico's law. CMS enforces outcomes for disputes resolved under federal processes.

This dual framework ensures patients are protected from surprise medical bills while providing clear guidance for reimbursement and dispute resolution.