Anthem members sue payer for inadequate notice of dropped providers
UPDATE: March 6, 2019: A Wednesday complaint amends the class-action lawsuit and claims Anthem made "multiple false marketing claims" to entice thousands of Georgia consumers to its ACA plans. The Doss Firm filing accuses Anthem of falsely advertising that WellStar and Emory would be in the insurer's network, along with falsely inflating the size of its hospital and physician network.
Two Georgia residents are suing Anthem and alleging the payer should have told them it planned to drop WellStar Health System services in 2019.
Members of Anthem Pathway, which is the individual health insurance plan, will pay out-of-network costs for WellStar providers. The payer agreed to delay considering WellStar's primary care providers out-of-network until May after a request from the Georgia Department of Insurance.
In a letter to Anthem members on Jan. 31, Atlanta-based WellStar said patients will be responsible for normal co-pays and deductibles and not "additional patient payment responsibilities" if Anthem considers the provider in-network. However, if the payer doesn't recognize the provider as in-network, WellStar said the patient "will be billed and responsible for payment for any difference between 'in-network' allowed amounts under our contract and the amount Anthem reimburses WellStar."
The 39-page lawsuit is the latest twist in the growing friction between payers and providers with patients stuck in the middle. These disputes can lead to inconvenienced patients, access issues and expensive surprise bills for patients. It can also result in patients delaying care rather than paying more out-of-pocket costs.
The suit alleges Anthem misrepresented that WellStar would be in-network for individual insurance members during the Affordable Care Act exchanges open enrollment period between Nov. 1 and Dec. 15. Anthem Pathways members are now locked into those plans despite not having in-network access to WellStar.
In a statement on Wednesday, WellStar said Anthem informed the health system on Aug. 8 that the payer was "terminating WellStar as a participating provider in their Pathways product ... We immediately disputed this action, and are pursuing all contractual rights we have to resolve this issue."
"We understands how difficult this is for patients who choose WellStar hospitals and physicians. WellStar was not able to notify Anthem members of this change, as we do not have a listing of individuals who signed up for this Anthem plan," the company said, adding the issue doesn't affect employer-sponsored health plans.
In its own statement Wednesday, Anthem said some consumers enrolled in Anthem Pathway plans "based on the incorrect assumption" that WellStar would remain in the Pathway network this year. The payer said its working with the Department of Insurance to find a solution. It agreed to extend benefits for 90 days to Pathway members so WellStar's primary care physicians will be considered in-network until May 4.
Anthem will pay the previously contracted reimbursement rate for primary care providers until that date, but warned members that it "cannot guarantee WellStar will permit Pathway members to schedule appointments, or will not bill members for the difference between the Anthem allowed reimbursement and WellStar's billed charges."
The squabble between Anthem and Wellstar puts patients at risk of receiving surprise bills, which are also called balance bills. It's when a patient is billed the difference between what the insurance pays and what the doctor actually charges. Federal laws are lacking in this area, but there are a handful of states with stronger surprise billing laws. Leaders in Washington are discussing the issue in hopes of passing legislation that would protect patients from exorbitant medical bills.
Surprise billing is becoming an increasingly common issue for consumers. Kaiser Family Foundation recently found that about 40% of Americans said they have received a surprise medical bill. More than two-thirds of those surveyed are at least somewhat worried about getting a surprise bill.
Payers and providers disagree on who's to blame. Payers blame providers for not participating in networks. Providers point the finger at payers for offering inadequate health plan provider networks.