Marietta’s Wellstar Kennestone Hospital, with more than 600 beds, is one of nearly a dozen Wellstar hospitals in Georgia.
Photo: COURTESY PHOTO
Photo: COURTESY PHOTO

Blow for ACA patients: Anthem/Blue Cross individuals lose Wellstar

Thousands of Georgia Obamacare customers who just signed up for 2019 coverage with the state’s biggest health insurance company are getting a surprise.

The Wellstar health care network of nearly a dozen hospitals, three health parks, 10 urgent care clinics and untold doctors will no longer be covered for individual policyholders as of Feb. 4, as the two companies are letting that contract expire rather than agree on a new one.

That leaves those customers of the insurance company — Anthem, formerly called Blue Cross Blue Shield of Georgia — to either avoid the Wellstar providers that dominate northwest metro Atlanta or pay colossal out-of-network costs.

The news is one more instance of customers bearing the brunt of skyrocketing medical costs and the industry’s disagreements on how to handle them.

“We’re at the point of potentially using medical expenses, and we’re going to have to go where?” said Martha Sanderson, an Anthem customer who lives just outside Marietta who says she carefully checked the insurer’s website to make sure her doctors were in network before she signed on two months ago.

She said she still has not received notice from Anthem.

“I feel like I’m paying $1,250 a month for something I didn’t know what it is,” Sanderson said.

In recent years, extraordinary demands have been made on customers such as Sanderson. Premium prices have soared well into four digits monthly, and large numbers of emergency room visits have been denied coverage after the fact. For one year, Anthem simply pulled out of metro Atlanta’s individual insurance market altogether, the first time in perhaps the company’s history.

Sanderson and other policyholders who don’t have employer-based health insurance — instead obtaining their coverage through the Affordable Care Act, also known as Obamacare, or off the exchange as individuals or groups, through agents are the weak party at the table. Health care providers are consolidating to negotiate tougher deals with health insurance companies, who in turn are both pulling back from the places they’ll cover and taking a tough line on what they’ll pay. Employer-based plans now account for less than half of Georgia’s patient coverage, according to the Kaiser Family Foundation.

Wellstar and Anthem would not provide the number of patients affected by the expiration of the contract.

This dispute might not be solved anytime soon, experts say, because the companies don’t have much at stake — only the patients do.

“The departure of WellStar from an (ACA) exchange product is not material to WellStar’s business or Anthem’s,” said Chris Kane, a health care insurance consultant. He added that when it comes to the health care business, “patients want to think about sunshine and rainbows, and hospitals and payers want to pummel each other from time to time.”

Some agents who sell individual Anthem policies, both on the ACA exchange and off it, said they had heard no announcement of the contract split.

“We’ve received nothing,” said Sanderson, the patient, who tried to book a checkup with her longtime doctor, who informed her about the dispute and turned her away. Now her county, Cobb, a place bigger in size and population than Denver, will have no hospital under her coverage.

Cindy Holtzman, an agent, asked for and received an email response from Anthem that confirmed the problem. It added that there may be “member abrasion” because computers would still automatically assign policyholders to Wellstar primary care physicians, and then they’ll have to be changed in February.

“The key thing is you can’t get through to their customer service,” Holtzman said. “Everyone who just enrolled in their plans for this year, they assign you a primary care doctor, you call to try and change it — you’re stuck on hold for hours. Well, now they just dumped all your doctors.”

Another agent described the distress of a patient with heart problems who appears to have lost coverage for her cardiologist. Anthem said it would provide continuity of care with the same providers for “those undergoing treatment,” but it did not say what that means.

Georgia state regulators received no heads up about the Anthem-Wellstar dispute, said Steve Manders, the director of insurance products at the Georgia Department of Insurance, which regulates whether companies are meeting legal standards with their insurance policies.

“They’re not required to tell us,” Manders said. “That’s not a transaction we approve or disapprove.”

Manders and his staff, after receiving calls from customers and The Atlanta Journal-Constitution, tried Friday to figure out what information had been provided to consumers. Looking hard, they found a couple of obscure sentences on Anthem’s website. The Insurance Department, under a new commissioner now, must now decide whether to try to persuade the companies to come to agreement.

Prospects for a solution don’t look good.

Unlike last year’s dispute between Anthem and the Piedmont Healthcare group of providers, the population at stake here is smaller and doesn’t contain big groups of patients who can negotiate en masse. In the Piedmont dispute, the companies agreed on a new contract within weeks and retroactively covered the customers’ claims. That contract covered all Anthem customers, not just those with individual policies. Perhaps a half-million patients were in play, including those with employer-based insurance. The companies had little choice but to come to terms.

What this might be, however — observers outside the companies imagine but can’t say for sure — is a shot across the bow for those bigger negotiations coming up.

Anthem and Wellstar each blamed the other for the contract impasse.

“Unfortunately, although WellStar has repeatedly requested a proposal from Anthem Blue Cross Blue Shield to participate in their Pathways health exchange products, we have not been offered a contract to participate,” Wellstar said in a statement, adding that it was “surprised and disappointed.”

Anthem shot back with its own statement: “Unfortunately, we could not come to an agreement on affordability with WellStar, which chose not to continue to participate in (Anthem’s Pathway product, the policy for individuals and some groups) as other providers have.”

Stay on top of what’s happening in Georgia government and politics at ajc.com/news/georgia-government/.

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