Story updated 2/6
Two Cobb County residents filed a lawsuit Tuesday against Anthem Blue Cross and Blue Shield, saying the insurer misled Georgia consumers into believing WellStar Health System was in its exchange network when they signed up for coverage.
The lawsuit, filed in federal court in Atlanta, is the latest chapter in the dispute over the exchange contract between Anthem and WellStar.
The contract was terminated Monday, affecting thousands of Georgians who have exchange coverage and individuals buying policies “off” the exchange. Anthem Blue Cross said Monday that it would allow another 90 days of network coverage for those members who selected, were assigned or tried to choose a WellStar-affiliated primary care physician.
But that extension did not appear to mollify either WellStar or the plaintiffs.
The lawsuit alleges that Anthem had notified WellStar in August 2018 that it would be ending the exchange contract with the Marietta-based health system. But despite that notification, Anthem did not inform potential customers looking for individual policies during Open Enrollment in November and December, the suit claims.
Attorney Jason Doss of the Doss Law Firm in Atlanta, who filed the suit, said the non-disclosure was a case of “a bait-and-switch’’ based on false advertising. Doss said the suit is considered a class-action complaint, seeking to cover others similarly affected.
Anthem spokesman Colin Manning said Tuesday that the company does not comment on pending litigation.
One of the plaintiffs, Frances Kirby, 56, said she chose Anthem because her longtime primary care physician and several of her specialists were WellStar doctors and were listed as part of the Indianapolis-based insurer’s network here. She said WellStar operates the only hospitals in Cobb County, where she lives.
Anthem “made uniform misrepresentations and omissions to consumers as well as its independent brokers during the enrollment process that WellStar would be an available provider to policyholders in Anthem’s Pathway Health Plan,’’ the lawsuit says. It alleges that Anthem concealed the contract termination from consumers ‘’for the purpose of inducing them to select Anthem as their health care provider.’’
The dispute does not apply to WellStar patients who have employer-based or Medicare Advantage coverage.
The biggest area of impact of the contract termination is in Cobb County and other northwest Atlanta suburbs, where WellStar dominates the health care market.
Also on Tuesday, James Budzinski, WellStar’s chief financial officer, told GHN that Anthem did not follow the designated protocols for ending the contract. He said the dispute will go through a mediation process in March.
“Blue Cross is not consulting us at all regarding how they’re going to handle the situation,’’ Budzinski told GHN.
WellStar said it’s sending letters to the more than 1,000 patients with Anthem exchange insurance that received services during January, before the contract cutoff.
Budzinski said the Marietta-based health system didn’t know which of its patients signed up for the exchange until those people sought medical care. “Only Anthem knew,’’ he said.
Anthem’s 90-day extension of network coverage, Budzinski pointed out, does not apply to WellStar’s specialist physicians nor its 11 hospitals.
Attorney Doss called the 90-day reprieve “a temporary Band-Aid’’ and a “non-solution.”
The lawsuit notes that the Open Enrollment for the exchange has ended, and that the plaintiffs are “locked into’’ their current plan till next year.
The second plaintiff, John David Marks, 63, said Tuesday that he had to cancel an appointment with his urologist because that doctor is no longer in network.
“I was diagnosed with prostate cancer a year and a half ago,’’ Marks told GHN. “I’m in a surveillance program.’’
He said he also has heart problems. He said that while a WellStar hospital is just 5 minutes away from his home, the closest non-WellStar hospital is 25 miles away.
Marks said he switched to Anthem in the exchange because there were more facilities available, the cost was cheaper, and WellStar providers were listed as part of the network.
“I have established relationships with these doctors,’’ he said. When told that he would be out of network for the urology visit, Marks said that he replied, “There must be some mistake.’’
Marks said of Anthem, “I want to hold these people accountable.’’
WellStar’s Budzinski said that during the 90-day extension, WellStar patients will face the same out-of-pocket costs if Anthem pays the doctors at a network rate.
But if the insurer pays the doctor below those rates, WellStar will bill the patient for the difference, he said.
Anthem’s Manning, though, said Tuesday that the insurer will pay the doctors at the regular contracted rate during the extension period.
The company is Georgia’s largest health insurer.
In a statement Monday, the insurer acknowledged that some Georgia consumers “may have enrolled in Anthem plans based on the incorrect assumption WellStar would remain in our Pathway network throughout 2019.’’
Anthem said it has worked closely with Georgia Insurance Commissioner Jim Beck to extend WellStar coverage beyond Monday. The insurer said it is sending letters to affected policyholders.
“We look forward to ensuring our members receive high-quality, affordable care through our network of participating providers and hospitals,” Anthem said. “Consumers with questions can call the number on the back of their Anthem ID card or go to anthem.com/wellstar.”