The vast majority of contract disputes between health insurers and hospital systems get settled before the existing deal lapses. The agreement comes sometimes within hours of the deadline.
One notable exception occurred last year, when Piedmont Healthcare’s contract with Blue Cross and Blue Shield of Georgia expired without a deal.
And now the standoff between Anthem Blue Cross and Blue Shield and Marietta-based WellStar Health System appears unlikely to be resolved before the current contract ends.
This coming Monday, the day after the Super Bowl is played in Atlanta, thousands of Georgians who signed up for insurance exchange or individual coverage for Anthem will face much higher costs for using WellStar hospitals and physicians. Those providers will be out of network Feb. 4.
Consumers say that when they signed up for Anthem coverage, WellStar was listed as part of the insurer’s network. The prospect of contract termination, they say, was not in the information provided late last year when people checked options in the exchange. (Insurance exchanges, created by the Affordable Care Act, help people who do not have employer or government insurance find coverage.)
Mike Harbert, 64, a real estate agent in Mableton, has had the same primary care physician for 28 years. But that may have to change in February. He says he was misled in signing up for Anthem because he checked to see whether WellStar was in its network and found that it was.
“I like to have a doctor I have confidence in,’’ said Harbert, who has pre-existing health conditions.
The biggest area of impact is in Cobb County and other northwest Atlanta suburbs, where WellStar dominates the health care market. WellStar has 11 hospitals, several of them in those suburbs.
“If you’re in Cobb County, it’s WellStar. You don’t have many choices,” said Dave Smith, a consultant with Kearny Street Consulting.
Georgia Insurance Commissioner Jim Beck told GHN on Monday that he plans to meet with Anthem representatives Tuesday about the contract termination. A spokesman said Beck ‘’is looking to Blue Cross to make an accommodation for consumers who relied on incorrect information on the company’s website when they made their plan selection.’’
The federal Centers for Medicare & Medicaid Services said Monday that a state is responsible for reviewing the adequacy of insurer networks. But CMS also said that it is aware of the Anthem/WellStar situation and is looking into the matter further.
The contract problem does not affect patients who have employer-provided or individual Medicare Advantage health care through Anthem.
New state Rep. Mary Frances Williams, a Marietta Democrat, says she has heard from constituents about the problem.
“I’m not looking for who to blame,’’ she told GHN. “I want them to work this out.’’
Those affected are the self-employed and small-business owners, Williams said. “It’s a deep concern,’’ especially for people who are getting ongoing care, such as cancer treatment, or women who are pregnant, she added.
In a statement, WellStar said it’s continuing to dispute Anthem’s termination of WellStar. “It appears unlikely that WellStar will be participating in the Pathways products past February 4, 2019,’’ the WellStar statement added.
Anthem spokesman Colin Manning issued a statement saying that “helping to ensure consumers have access to Individual health plans that offer greater affordability and access to quality health care remains our focus at Anthem Blue Cross and Blue Shield. Unfortunately, we could not come to an agreement on affordability with WellStar, which chose not to continue to participate in Pathway as other providers have. We are working to transition our consumers to other providers.’’
Scott Wright, 57, of Marietta, a small business owner, said he hopes for a Special Enrollment Period so he can enroll in another health plan.
“I’m frustrated,’’ said Wright. “I’m guessing I’m one of thousands affected by the situation. My situation isn’t unique.”
“I researched the plan. The WellStar system was under the plan. I wouldn’t have selected a plan that didn’t have this option. I made a health care decision based on providers I would see.’’
Special Enrollment Periods for individuals in the exchange market are granted mostly for those who have experienced a change in their personal circumstances, such as a marriage, childbirth, a divorce, a household move, or loss of health insurance.
In Georgia, though, there was an extended enrollment period in the exchange for a group of people — those in counties hit hard by Hurricane Michael.