Georgia regulators facilitate agreement in Anthem-WellStar spat

Anthem and WellStar have reached an agreement, facilitated by Georgia insurance regulators. (Getty/suesmith2)

Georgia insurance regulators have intervened in an ongoing spat between Anthem and WellStar Health System. 

A group of Georgia residents filed suit against the insurer in February, arguing that it had misled them about the provider network for its Pathway plan on the Affordable Care Act exchanges. Anthem and WellStar failed to reach a network agreement, but the insurer was advertising WellStar as in-network during open enrollment, the lawsuit alleges.

Anthem on Wednesday agreed to enter into a consent order (PDF) with WellStar, coordinated by the state’s insurance and fire safety commissioner, which ensures that people enrolled in the Pathway plan will be covered for primary and specialty care at in-network rates through the end of the year. 

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The agreement allows Anthem to avoid a planned hearing on the matter that was set for the end of May. The decree is limited, however, to primary and specialty care—inpatient and outpatient services are not included. 

RELATED: Anthem boosts 2019 financial forecast as it prepares to launch PBM IngenioRx 

Anthem informed WellStar that it would not be in-network for the Pathway plan in August of 2018, according to the lawsuit, but members did not learn that until after they were already enrolled in the plan. 

Georgia residents also amended the suit to seek a special enrollment period that would allow them to switch from Anthem’s plan and select a plan that does offer WellStar coverage. Anthem offered an extended coverage window of 90 days at WellStar facilities as a mea culpa. 

The consent order does not address a second accusation from Pathway enrollees: that Anthem misled them about in-network care at Emory Healthcare as well.  

In the second version of the lawsuit, the Georgians also said they were notified by Anthem after enrollment that their contracts incorrectly said they could seek specialty care without needing a referral—when, in fact, it was the opposite. 

They expressed concern about the impact this could have on their care, as the plaintiffs in the case each had a chronic illness that required close care management. 

Anthem told FierceHealthcare in March that “consumer-facing materials” for the plans warned potential enrollees that referrals were required, though the contracts were incorrect.  

Attorneys for the Pathway plan members said that these issues reflected a “pattern of deception” on the part of Anthem. 

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