Anthem hit with lawsuit alleging it misled enrollees in Georgia’s ACA exchanges

lawsuit and book
Georgia patients say Anthem misled them about the provider network for its ACA plan. (Getty/eccolo74)

Georgia patients have filed suit against Anthem, claiming that the insurer misled them about the provider network it would offer through its Affordable Care Act plan.

In the lawsuit (PDF), filed by the Atlanta-based Doss Firm on behalf of the enrollees, the patients say they were assured that care at WellStar Health System facilities would be covered under the ACA exchange plan. Those assurances continued even as Anthem’s deal with WellStar began to break down in the summer, well ahead of open enrollment.

Jason Doss, one of the attorneys on the case, said in a call with reporters that WellStar and Anthem had failed to reach a deal in August, but ACA marketing during open enrollment portrayed the state’s largest health system as an in-network option. The marketing, he said, amounts to a “bait and switch” on consumers.

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“The facts here are clear,” Doss said. “Anthem concealed the truth from Georgia health consumers in order to induce them to select them as their health insurance company.”

In a statement to FierceHealthcare, Anthem said it does not comment on pending litigation. But the insurer acknowledged that some consumers may have signed up for its Pathway ACA plan under the “incorrect assumption” that WellStar would be in-network.

The insurer did offer a temporary fix to enrollees who were current WellStar patients, by extending coverage at the health system’s facilities for an additional 90 days. It encouraged patients with further questions to reach out for additional information about their coverage options.

During the extended window, Anthem said it would cover care provided by WellStar primary care physicians at previous rates, but said it could not guarantee that the system would allow Pathway members to schedule appointments or that WellStar would not bill patients directly for any charges above those reimbursement rates.

“We look forward to ensuring our members receive high-quality, affordable care through our network of participating providers and hospitals,” Anthem said.

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But Doss said the extension is not enough to meet the needs of many of these patients.

Francis Kirby, a Georgia resident who just signed up for the Anthem plan and is one of the named plaintiffs on the suit, said on the call that she sees nine different WellStar specialists to manage her health, and that she is expecting a lapse in care as she seeks out new providers and a new primary care physician.

Doss said there are “thousands” of other Georgians in the same situation as Kirby.

“Thousands of Georgia consumers were misled by misrepresentations and omissions,” he said.

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