Two Cobb County residents have filed a class-action lawsuit against Anthem, saying the insurer tricked them into locking down a 2019 policy months ago without telling them it was already planning to drop the WellStar doctors and health services they use from its covered network.
On Monday, individual Anthem customers were cut off from using WellStar unless they pay high out-of-network costs. That evening, prodded by the state Department of Insurance, Anthem issued a reprieve for some services, delaying the cutoff until May 4. The reprieve appears only to apply to use of primary care doctors, but Anthem — formerly known as Blue Cross Blue Shield of Georgia — could not confirm that Tuesday.
The dispute does not apply to Anthem customers who have employer-sponsored insurance, just individuals with Anthem Pathways policies, such as those obtained on the Obamacare exchange.
The Doss Law Firm, which is representing the plaintiffs in the suit, called the reprieve "at best a temporary and limited nonsolution" that only prolongs the uncertainty for WellStar patients.
In announcing the reprieve, Anthem acknowledged that some customers had felt blindsided by the loss of WellStar, which dominates northwest metro Atlanta. Policyholders on the individual market chose their policies in late fall, when Anthem already knew it was canceling the WellStar contract for those customers. Then the customers learned through their doctors or news stories that they'd lose WellStar early this year, after they were locked into Anthem for all of 2019.
Jason Doss, one of the plaintiffs’ attorneys, said his clients looked diligently on the Anthem website and were informed only that their WellStar providers would be in network.
“I received no notification of this change from Anthem and had to read about it in a news release,” said one of Doss’ clients, Frances Kirby. “I will now be forced to search for a new primary care physician and several new medical specialists. This will assuredly cause a lapse in my medical treatment.”
Doss said the exact number of afffected patients is unclear but is likely in the thousands. The firm aims for the suit to encompass all of them, he said, if a court agrees. The suit was filed in federal court in Atlanta.
In announcing the reprieve Tuesday night, Anthem said that for 90 more days it will pay in-network fees for primary care physician services from WellStar. In-network fees are higher for the insurer than out-of-network fees.
It did not mention other services, such as specialist doctors or hospital services. And it said that it was up to WellStar to decide whether to also treat those patients as in-network, which would mean continuing to lower its list price for them and refrain from billing them beyond co-pays and allowed out-of-pocket limits.
Scott Wright, a Marietta resident who chose Anthem so he could see his WellStar providers, was livid.
"Where to start?" he wrote in an email. "To say that certain patients may be allowed to see their (primary care doctor) through May 4 does very little to make me feel secure. And then WellStar may bill us for any shortfall? What about … tests (routine or otherwise)? What if me or a family member needs an operation or procedure?"
WellStar’s chief financial officer, Jim Budzinski, said the first he’d heard about Anthem’s reprieve was from The Atlanta Journal-Constitution.
He said it appeared to WellStar that Anthem was only applying the reprieve to WellStar’s primary care services, not other services such as specialist doctors and hospital services.
WellStar officials said that as long as Anthem continues to treat primary care visits as in-network, WellStar will, too.
But for services where Anthem treats patients as out of network and pays the lower out-of-network fee, WellStar says patients will no longer just pay a co-pay. They’ll be responsible for whatever Anthem doesn’t pay. WellStar is making a concession to those patients, though, and will consider the price of the service to be the lower network price, as opposed to the public list price.
Anthem and WellStar have each blamed each other for the dispute.
Budzinski says the contract would have renewed automatically if Anthem had not written WellStar in August that it was unilaterally canceling that part of their contract. The letter followed “very brief” discussions where Anthem was asking to lower its rates, Budzinski said. WellStar said Anthem did not have the right to break that part of the contract, and Anthem disagreed.
An Anthem spokesman said the company chose May 4 as the reprieve deadline in order for those members with its Pathways policy to have extra time to transition to in-network primary care physicians.
In March the two companies are scheduled to go through mediation to try to resolve the dispute. The mediation is a step the contract lays out.
Wright, the patient, said any extension should be for all of 2019, since that’s how long he’s locked into his policy unless the federal government allows him to get out of his Affordable Care Act individual plan. He’s asked for permission and still hasn’t heard back.
Wright said he was offended by a line in the Anthem announcement implying he should have known WellStar would go out of network. He’d looked up his WellStar providers on Anthem’s website while choosing his 2019 plan, he said.
“The main tool for determining which providers were in network indicated that WellStar was in network, and there was no information that that status was only short-term,” he said.
Anthem said in its announcement that such customers had made an “incorrect assumption.” State regulators said there appeared to be a couple of obscure sentences on Anthem’s website pointing to the WellStar problem to come.
Anthem has provided its customers the name of a new primary care doctor to see, though one woman said hers turned out to be a pediatrician.
Asked whether he predicted the contract dispute could be solved by May 4, Budzinski didn’t know: “I can’t say.”
ANTHEM’S STATEMENT
“It has come to our attention some consumers may have enrolled in Anthem plans based on the incorrect assumption WellStar would remain in our Pathway network throughout 2019. We have worked closely with Commissioner (Jim) Beck and the Department of Insurance to find a solution that allows impacted Pathway members to receive care from WellStar primary care providers beyond February 4, 2019. We are extending benefits for 90 days to Pathway members who selected, were assigned or attempted to choose a WellStar affiliated primary care physician. This means the impacted Anthem Pathway Member can receive treatment from WellStar (primary care physicians) until May 4, 2019, and Anthem will allow the previously contracted reimbursement rate, although we cannot guarantee WellStar will permit Pathway Members to schedule an appointment, or will not bill members for the difference between the Anthem allowed reimbursement and WellStar’s billed charges.
“We look forward to ensuring our members receive high quality, affordable care through our network of participating providers and hospitals. Consumers with questions can call the number on the back of their Anthem ID card or go to anthem.com/wellstar.”
WELLSTAR LETTER
On Friday, WellStar wrote to patients affected by Anthem’s contract decision on what the impact would be to their payments. The impact may be different for different services. For example, Anthem may decide to treat a primary care doctor visit as in-network but treat a visit to a specialist as out of network. This is an excerpt from that letter:
- If Anthem recognizes WellStar as an "in-network" Pathways provider, your patient payment responsibilities will be limited to normal co-pays and deductibles and will not result in any additional patient payment responsibilities.
- If Anthem does not recognize WellStar as an "in-network" provider, you will be billed and responsible for payment for any difference between "in-network" allowed amounts under our contract and the amount Anthem reimburses WellStar.
- WellStar will bill Anthem first, before billing you, to ascertain Anthem's policy determination of whether WellStar is "in-network" or "out-of-network" for the Pathways product.
