Anthem/Blue Cross to some Georgia clients: Your contract is mistaken

State asks feds to let Anthem ACA patients re-enroll
Anthem’s corporate headquarters in Indianapolis. Anthem in this state was formerly known as Blue Cross Blue Shield of Georgia. (AP Photo/Michael Conroy)

Anthem’s corporate headquarters in Indianapolis. Anthem in this state was formerly known as Blue Cross Blue Shield of Georgia. (AP Photo/Michael Conroy)

Last year, the insurance giant Anthem made a contract with its individual policyholders. They could keep going to their specialists, the contract said, without a referral from a primary care doctor.

Now Anthem says that was a mistake. In reality, Anthem told some Georgia customers in a Feb. 21 letter, “Your plan does require a referral to see a specialist.” It apologized for any confusion.

Anthem, formerly known here as Blue Cross Blue Shield of Georgia, is on the receiving end of a number of federal lawsuits over its interpretations of coverage. The Feb. 21 letter will be a new filing, Atlanta lawyer Jason Doss said.

How a contract can be one thing when signed in black and white, and another thing months later when Anthem decides it’s the opposite, is a mystery to Kelley Johnson. Her husband just had open-heart surgery and was turned away from his cardiologist last week when his fever started to spike. Their lawyer, Doss, has filed suit against Anthem for other actions and plans to demand that a federal judge put an immediate stop to insurer’s plan to change its contract.

“I said you’re telling me my husband who just had open-heart surgery, who’s running a fever of 101.3, cannot be seen by the doctor who’s been seeing him for a year?

“It’s wrong,” she said. “I mean it’s wrong.”

Anthem said Monday evening that it cannot respond to questions because of pending litigation.

The Georgia Department of Insurance and the federal Centers for Medicare and Medicaid Services would both have to approve any change to an insurance plan obtained through the Affordable Care Act exchange , said Tom Carswell, the assistant director of the product review division with the state agency.

Reached out of the office at the end of the day, Carswell was not aware of this plan change. But he said it was possible, if the provision had been mentioned in multiple places in contract documents: correctly in some places, incorrectly in another. This one, if mistaken, could be a major error, he said. The Insurance Department might ask the insurer to give the patients some buffer time to sort out their providers.

Anthem has led the way the past two years in bold decisions to lower its payment of rising health care costs. It has narrowed its provider networks, refusing to cover visits to some doctors and hospitals. It has refused to cover some emergency room patients after it decided they didn't really have an emergency. It has made national headlines, and in the process, it brought to light some of the outsized prices charged by hospitals in general and some other health care providers.

In that fight among health care giants, though, patients have had little or no voice.

The Anthem contract language, according to Doss’ filing, says that Anthem can change the contract “by giving (the policyholder) written notice of the amendment at least 90 days before the amendment takes effect. You must agree to the change in writing.”

After Johnson talked to her husband's cardiologist's office, she couldn't call their primary care doctor. That doctor is in the WellStar Health System, and Anthem decided to drop WellStar from its network. It made the decision last year but did not send notification to the patients, several patients said. They found out in January from their doctors or the AJC, after they were locked in for a new year on an ACA plan. The state Insurance Department has asked the federal government to let patients redo their enrollment, but no permission has been given yet.

Johnson took her husband to the emergency room, risking a massive hospital bill, because it was the only place that knew his case where they could just walk in. Johnson and Doss said that he turned out to have pneumonia and is still in the hospital.

“The scary part of someone who’s just had heart surgery is taking someone into an ER during flu season,” Johnson said. “I really wanted to get him seen by a doctor. … There were a lot of people with masks.”

Johnson said they signed up with Anthem last year specifically because they knew the heart problem would need care and all their providers were in the WellStar network. They’ve been sideswiped by the recent network tumult. But after threatening to sue, they received a letter from Anthem saying the surgery and follow-up visits would be in-network. They haven’t talked to Anthem yet to confirm the follow-up ER visit is covered.

“I’ve broken down a number of times,” Johnson said. “I think it’s wrong to put yourself out there as an insurance company that covers you, as someone that’s going to take care of you and pay your in-network providers, and then sort of take all of that away. … Suddenly, you get a letter in the mail saying: ‘Oh, no the contract is wrong’? It’s immoral. It should be illegal.”