Healthcare standoff leaves 500,000 patients in limbo

Saturday night's stalemate between Blue Cross Blue Shield of Georgia and Piedmont Healthcare over a new contract will force at least half a million Georgia Piedmont patients to pay out-of-network costs for their current doctors.

Negotiations will continue, said Matt Gove, Piedmont Healthcare’s chief consumer officer.

The two companies, Georgia’s largest health insurer and one of the state’s largest health care provider groups, have been in tense negotiations for weeks over their contract renewal. The previous contract ended Saturday night. The menu of issues at stake included how much Blue Cross would reimburse Piedmont and its doctors for services, and terms such as what services it would cover.

The companies have not detailed the key sticking points, but they have been in court over Blue Cross’ reluctance to fund some in-hospital MRIs and CAT scans when they can be done for less elsewhere, and to fund emergency-room care when Blue Cross decides it was not warranted. A Piedmont spokesman also said doctor payments were a roadblock.

For patients with imminent need for care, the failure now means uncertainty. In a few circumstances of ongoing care, network prices will be grandfathered in. But for most, they must either find a new care provider or risk being stuck with much higher out-of-network costs such as copays if they go to their familiar caregiver.

Gove said 72 hours of heavy negotiations was abruptly upended just before midnight.

“Unfortunately, as we reached the deadline, (Blue Cross Blue Shield of Georgia parent company) Anthem decided instead of building on the progress we thought we had been making, they reverted to a 5-day-old unacceptable proposal they sent us early last week, and said ‘that’s our offer,’” Gove said.

Colin Manning, an Anthem spokesman, responded with a statement from the company.

“We apologize to our consumers for any disruption this may cause and we are working hard to reach an agreement that will bring Piedmont back into network as quickly as possible,” the statement said. “In the meantime, we are taking steps to help ensure our consumers have uninterrupted access to affordable health care across our broad network of providers in Georgia.”

Piedmont Healthcare posted a note to its patients late Sunday morning announcing the stalemate, pointing a finger at Anthem.

“People should be paid fairly for the good work they do.” the note states. “This is part of the fabric of our country and a core value we share with our communities. What Anthem Blue Cross is offering our doctors does not even cover the annual rate of inflation, but they will tell you that we are asking for unfair rate increases.

“One only needs to look at the small community hospitals – across Georgia and the country – that are closing their doors to see why fair rates are important.”

The negotiations immediately affect about a half-million current patients across the state, who have seen a Piedmont provider within the last 18 months. There are some 2 million Blue Cross Georgia customers who could have used Piedmont as an in-network provider.

The impact is broader because Piedmont Healthcare has been expanding recently, purchasing facilities such as Rockdale Medical Center in October and the giant Athens Regional Medical Center in 2016. National studies on hospital networks show that such expansion may give Piedmont more leverage in negotiating higher prices.

It's not the first time an insurance company has been unable to come to terms with an important hospital. In 2016 Piedmont patients with United Healthcare insurance endured a nearly two-month standoff between those two companies. Their services were eventually grandfathered in.

In recent days, a major group of customers received new insurance cards from Blue Cross with their doctor's name replaced. More than 100 lawmakers received a letter Thursday from Piedmont suggesting that Blue Cross intended to end the contract. The insurance provider posted a note to its customers Friday detailing how they could be affected and what services could carry over should no contract agreement exist Sunday morning. In a Sunday afternoon update, Blue Cross Georgia provided information on Continuation of Care coverage, which includes what would still be paid for with Piedmont care providers.

Negotiations have gone down to the wire previously, but Piedmont has sued Blue Cross and its parent company, Anthem Inc., over a decision to no longer pay for some in-hospital MRIs and for emergency room visits the insurer deemed unwarranted.

Blue Cross Georgia customer Marrielle Myers said she just found the perfect primary care physician this year. She’s been several times since her first appointment in February, and worries about losing a new doctor with whom she’s already formed a great relationship.

“She’s just real with me,” said Myers, an assistant professor of elementary mathematics education at Kennesaw State University. “I went in and she was like, ‘Girl, what is up with your blood pressure?’ I have never had a relationship with a doctor like this.”

Myers said she received a letter in February warning her about the potential changes, but was reassured by staff in her physician’s office that the companies likely would find an agreement before the deadline.

“Everybody said they go through this all the time, and it’ll be fine,” she said. “But I guess it’s not.”