Medical providers upset over health plan collections

Despite recent changes to ease employees’ concerns, the State Health Benefit Plan can’t seem to escape controversy.

Medical groups told GHN this week that they’re upset about having to collect money from state employees and teachers – payments that are linked to a benefits shift earlier this year.

These provider organizations say they’re being told by Blue Cross and Blue Shield of Georgia, the main insurer for the SHBP, that they must recoup money from patients in the wake of a change to a co-pay system that became effective in March.

Tyler Riddle
Tyler Riddle

“Providers are being told by Blue Cross that we have to remit this payment,’’ said Tyler Riddle of Albany-based MRS Homecare, a medical equipment company. “Then we have to recoup from the patient.’’

Under that scenario, Riddle said, “We’re expected to be the ‘bad guy.’’’

The largest physicians organization in the state, the Medical Association of Georgia, said Tuesday that it “believes that this recoupment effort represents an unreasonable financial and administrative hardship for medical practices.”

The State Health Benefit Plan covers 650,000 state employees, teachers, other school personnel, retirees and dependents. With those numbers, the plan’s members can be a strong political force in an election year such as this one.

Changes in the health plan, starting Jan. 1, created fierce criticism from members, who complained about a lack of choice of insurance plans and higher health care costs. A Facebook group attracted thousands of members, and teachers and employees rallied at the state Capitol.

The board of the Department of Community Health, responding to the uproar, approved a plan to replace co-insurance — a patient paying a percentage of the costs of a health service — with a co-pay system for medical services and prescription drugs. The change, effective in mid-March, was retroactive to Jan. 1.

The change was made to ease the financial burden on SHBP members.


Some consumers were expected to get a rebate or credit on their previous health care transactions for this year, as a result of the switch.

But Community Health also said at the time that some patients may end up owing money if they have received care in 2014 and had first-dollar coverage with their health reimbursement arrangement.

The agency issued an email statement to GHN that said, in part, that Blue Cross has communicated with providers about “the necessary reprocessing of claims as a result of the plan design changes.”

Blue Cross said in an email statement Tuesday, “The SHBP plan design changes require providers to retroactively collect co-pays and provide refunds for claims paid from January 1, 2014 through March 14, 2014.”

The recoupment effort, which started at the end of May, has irked medical organizations and companies.

The Georgia Association of Medical Equipment Suppliers (GAMES) issued a statement Tuesday saying, “Patients do not seem to be aware they should pay these co-payments retroactively as indicated by [Blue Cross]. Instead they view this as the [medical equipment] provider attempting to collect something the patient believes was covered.”

In many cases, GAMES said, the medical provider will simply have to pay the fees out of pocket because Blue Cross has indicated they will recoup the funds from future reimbursements.

A Tuesday statement from Donald J. Palmisano Jr., CEO of the Medical Association of Georgia, said the organization “believes that Blue Cross and Blue Shield and DCH should cover the administrative costs that are associated with the recoupment effort, including staff time and postage.”

“It is also worth noting that many patients don’t know or don’t believe they are responsible for the charge. And given the significant cash flow implications for medical practices, MAG does not believe that it is reasonable to recoup three months of claims at one time.”

And Jimmy Lewis of HomeTown Health, an organization of rural hospitals, said Wednesday that providers had no input in the process. “It continues to create an administrative and cash flow burden, and creates a trust and credibility problem between providers and patients,” Lewis said.

In the wake of the furor over the Jan. 1 changes, state officials are now planning to increase the number of insurers and health plan options for state employees and teachers next year.

The Department of Community Health has asked for proposals for a second statewide insurer to offer a high-deductible health plan, a Medicare Advantage plan for retirees, and a statewide HMO.

The current single insurer for SHBP, Blue Cross and Blue Shield of Georgia, would retain its health reimbursement arrangement plans and Medicare Advantage plans, plus add a statewide HMO option for the 2015 plan year. A third insurer would offer a fully insured in-network-only option for metro Atlanta, under the Community Health plan.

Separately, the AJC reported last month that a lawsuit filed against Community Health alleges that the state is overcharging thousands of teachers, state employees and retirees for their health insurance in the SHBP.

A Community Health spokeswoman said the agency does not comment on pending litigation.