The state of Georgia has fined Blue Cross Blue Shield, also known as Anthem, $5 million for a repeated, years-long pattern of violations of policyholder’s rights, the largest fine ever levied by the Office of Insurance and Safety Fire Commissioner.
“Since my first day in office we have been inundated with complaints about Anthem from individuals, from doctors, hospitals and others from all corners and across Georgia,” Commissioner John King said in a press conference Tuesday morning at the state Capitol.
The central problem, King said, has been the inaccuracy of Anthem’s list of health care providers, called its network. Patients often decide which insurer to buy a policy from based on whether their doctor or hospital is “in network” with that insurance company. For that to happen, the insurance company has to have its own contract with that doctor or hospital.
But often, King said, patients saw their doctor or hospital listed on Anthem’s network, and then found out later that it wasn’t true. That either left the patient paying the full price for service, or the care provider not getting paid.
Anthem Blue Cross and Blue Shield said in a statement that the database the investigation focused on has been replaced with a new platform, and that Anthem “worked diligently to address these challenges.”
“We are dedicated to those we serve and partner with, and we believe the recent enhancements we have made will create an improved overall care provider experience,” Anthem said.
The fine addresses mistakes Anthem made with its database. It does not address incidents where Anthem has informed policyholders in the middle of their contract that it is changing the network the policyholder originally signed up for. Such changes have long been protected by Georgia law. A new law in effect less than a year partly addresses that problem.
Such mid-contract changes are an issue Georgians have faced recently not just with Anthem but with other insurance companies, including UnitedHealthcare.
Credit: HYOSUB SHIN / AJC
Credit: HYOSUB SHIN / AJC
Often the impasses come because the care providers and the insurance companies cannot agree on the level of reimbursement the insurance should have to pay.
UnitedHealthcare recently reached a contract impasse with Northside Hospital, leaving patients stranded for five months. Currently, only a judge’s order is keeping Northside Hospital patients covered by Anthem, as Northside and Anthem are in a similar contract impasse. Approximately 400,000 patients are affected by that dispute.
At one point before the new law passed, Anthem summarily dropped the Wellstar hospital and doctor network with more than 1,000 providers from its individual policies. Cobb County has no other hospitals but Wellstar.
Those patients sued, alleging that Anthem knew it was going to drop Wellstar and advertised Wellstar as in network anyway. Those patients have twice defeated Anthem’s attempt to quash the suit, but will have to wait for a final verdict to see if their insurance claims will be paid. The suit was filed in 2019.
The lawyer in that case, Jason Doss, called the fine against Anthem, “a good first step.”
Georgia law had allowed insurance companies to promise a contract to a customer based on a certain list of network hospitals and doctors, with no penalty for changing that list in the middle of the contract. The only requirement was that the patient be notified. Now, the new law says that the providers on the list the patient signed up for should be treated as in network for 180 days after a change is made, in most cases.
A legislator who serves on Georgia’s House Insurance Committee, Rep. Lee Hawkins, R-Gainesville, on Tuesday joined King at the podium for the announcement on Anthem. Asked by a reporter whether Georgians should be able to rely on Anthem’s original provider list as if it were a contract, Hawkins said that backing that up with law would have the state meddling in a company’s contract language, and “That’s something that as a free market we try to stay away from.”
The fine levied Tuesday cites problems with the Anthem/Blue Cross database that went on for years, with complaints starting to ratchet up in 2015. One of the worst examples, said the office’s executive counsel, Gregg Conley, was a health care provider courted by Anthem to be in network. The provider signed up and advertised to their patients that they were in network. But, for some reason Anthem did not upload that provider to its computer system for a year. The patients expected to be insured but then were told they couldn’t get their claims paid.
The incidents have been reported for years, including under King’s predecessors. King said this investigation began approximately a year ago. Asked what took so long, he could not say whether a specific incident prompted it, but the decision came after listening to so many complaints from across the state.
King was appointed by Gov. Brian Kemp on July 1, 2019, to replace former Commissioner Jim Beck, who was indicted on fraud charges and has since been convicted.
Anthem has sway in Georgia. For years, many counties in Georgia would have had no option for coverage under the Affordable Care Act’s marketplace if not for Anthem agreeing to stay in those counties. The insurance office negotiated with Anthem to stay under King’s predecessor, but King said that had no bearing on whether or not the company was investigated.
Anthem is Georgia’s largest health insurance company, with nearly 3 million people in the state covered under Anthem/Blue Cross policies. Many of those don’t choose their own policies, but instead get whatever their employer chooses. However, Anthem has long been the biggest insurer on Georgia’s individual market, where every fall a half million Georgians choose between carriers during open enrollment. Some people choose their company based on which carriers have their doctor or hospital in network.
CONSENT ORDER
On Tuesday, the Georgia Commissioner of Insurance and Safety Fire fined Anthem/Blue Cross Blue Shield for consumer violations. Anthem said it would continue to cooperate with the state. These are some of the terms.
- Pay the state $5 million.
- Adhere to a Corrective Action Plan with milestones that must be met.
- File monthly reports for a year unless the state terminates the order earlier.
- Submit to periodic examinations to determine compliance.
- File a complaint system process with the state by April 30.
- Obtain state approval if Anthem wishes to issue an ordinary dividend of $100 million or more.
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