A top state regulator said the health insurance giant Anthem may have violated the law when it terminated WellStar Health System from its individual coverage, and he has ordered the company to appear at a hearing to explain itself.
State Insurance Commissioner Jim Beck made the statements in an order he issued Friday. Anthem is formerly known as Blue Cross.
The order concerns Anthem’s decision enacted this year to drop its contract with WellStar for individual policyholders after those policyholders were already locked in to their plans for 2019. WellStar has the only hospitals in Cobb County and is the main health care provider for northwest metro Atlanta, with more than 1,000 doctors and 250 medical offices.
The individual Anthem plans, called “Pathway,” do not provide for out-of-network rates, so those policyholders said they would pay the entire cost of a WellStar service in cash with no negotiated rate.
Anthem said it had done nothing wrong, had worked with affected policyholders to give them options, and would be at the hearing to present its case.
“Anthem has done nothing that is misleading, unfair or deceptive,” the company said in a statement. “Anthem will continue to work to ensure our members receive high quality, affordable care through our network of participating providers and hospitals.”
Beck scheduled the hearing for May 29. Policyholders who lost their WellStar caregivers say they’ve been asked to testify.
“I’m happy somebody else is going to take a stand against it,” said Audrey Logan, 27, who suffered heart failure after having a baby last year and now needs a heart transplant. All her caregivers and her hospital are WellStar. The Acworth resident now must go to Tennessee for all her care. She expects to testify.
“It’s totally devastating, I can’t breathe, I can’t walk long distances, I’m in heart failure,” she said. “If something happens, if I get a lot worse, what’s going to happen?”
Beck used strong language. He said in his order calling for the hearing that he “has reason to believe” that Anthem/Blue Cross “has been engaged in or is engaging in an unfair method of competition or an unfair or deceptive act or practice in this state, in violation of (Georgia law).”
Even if he hears the testimony from both sides and issues findings of fact against Anthem, however, it remains to be seen what he will accomplish. The Department of Insurance, which he runs, has the power to revoke an insurance company’s license, to issue fines or to negotiate compromises. The department has already been negotiating with Anthem, and so far the company only agreed to a limited reprieve for a portion of its Wellstar visits that has passed now.
What Logan’s lawyer, Jason Doss, really hopes will happen is that the federal government and the courts will pay attention to Beck’s findings.
It is the Trump administration, under the Centers for Medicare and Medicaid Services, that has the power to reopen the open enrollment period for Anthem customers and allow them to switch policies. The state has been in “constant conversation” with the CMS on the issue, but the federal agency appears to be unwilling to do that, said a spokesman for the Insurance Department, Brandon Wright.
In addition, Logan’s suit is filed as a class action affecting perhaps thousands of patients, and Beck’s findings will likely be cited by one side or the other in arguments to sway the judge.
Anthem and other insurance companies have been pushing back against hospitals’ and some other caregivers’ soaring prices for services. That’s not new.
What made Anthem’s actions with WellStar remarkable was that Anthem appears to have decided last year to drop the contract, and wrote as much in notice to WellStar. But potential customers who perused its online provider listings during open enrollment say that last fall they read that WellStar would still be an option in 2019. “I saw it,” Logan said. “My husband saw it.”
Anthem has said in statements that the patients made "an incorrect assumption."
Then when those patients went to see their doctors in early 2019, it was there they heard the news.
One after the other, Logan’s specialists told her they could no longer see her — or could see her for cash, about $1,000 per visit.
“I think it took a little while to sink in,” Logan said. “I was just hoping and praying it wasn’t happening.”
WHY IT MATTERS
Perhaps thousands of Georgia patients lost their caregivers when Anthem, formerly known as Blue Cross, dropped the WellStar Health System from its individual Pathway networks early this year. Those patients said they verified WellStar was in network before they signed up, and now they’re locked in for all of 2019. Emory and Piedmont were already not in the Anthem individual network, the patients say, leaving some patients to go out of state for care. The federal government and the courts have the power to give the patients options, but so far they haven’t. The state insurance commissioner has the power to levy fines that might bring Anthem to the table for a compromise.
Anthem’s statement
“Anthem has worked closely with Commissioner Beck and the Department of Insurance throughout 2019 to assist consumers who wrongly assumed WellStar would be in the Pathway network. Anthem has provided numerous options to help those consumers, and Anthem will continue to work with the Commissioner on these issues. With respect to the Commissioner’s request for a hearing, Anthem will be present at the hearing and present information that makes clear that Anthem has done nothing that is misleading, unfair or deceptive. Anthem will continue to work to ensure our members receive high quality, affordable care through our network of participating providers and hospitals.”
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