Georgians sue to switch ACA plans, say Anthem deceived them about its provider network

Gavel court room lawsuit judge
Georgians are suing Anthem with the hopes of getting into a new ACA plan. They say they were deceived about the insurers' provider networks. (Pixabay)

Georgia residents engaged in a legal battle against Anthem are asking for a “special enrollment period” where they could switch to a new insurer.

The residents initially filed suit against Anthem in early February, saying it engaged in deceptive marketing practices, misrepresenting its network to potential members of its Affordable Care Act plan, the Pathway HMO.

Anthem failed to reach a network deal with WellStar Health System last summer but said during open enrollment that care would be covered at WellStar facilities, according to the lawsuit. Anthem offered an additional 90 days of coverage at WellStar locations as a stopgap measure while members switched providers.

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In the updated complaint (PDF), the initial plaintiffs are joined by other residents who are seeking the opportunity to change their coverage for 2019.

“The harm caused by Anthem’s scheme cannot be overstated,” the complaint says.

RELATED: DOJ cleared to force testimony from Anthem in Medicare Advantage fraud investigation

In the updated version of the suit, the patients add that they were misled that care at a second provider, Emory Healthcare, would be in-network.

In addition, the plaintiffs received notification (PDF) from Anthem last week that their member contracts incorrectly said they can seek specialty care without a referral, when a referral is instead required.

This could lead to additional delays for care and increase costs, as these patients would have to visit a primary care provider first, according to the complaint. Each of the plaintiffs are patients with chronic conditions that require care management.

In a statement emailed to FierceHealthcare, Anthem said that "consumer-facing materials" advertising the plans did note that referrals were required for specialty care, though the contracts did include the wrong information. When the error was discovered, Anthem notified members and the state insurance department.

In the contract, two instances noted accurately that members would need referrals to see a specialist, while a third mention was inaccurate, Anthem said.

"We are committed to offering our consumers access to high quality, affordable care through our network of participating providers and hospitals," it said.

Joy Doss, an attorney with the Atlanta-based Doss Firm, which is representing the patients, said in a statement emailed to FierceHealthcare that the “extraordinary situation” warrants another chance for the people impacted to choose an insurer.

“Otherwise, any health insurer would play these games going forward,” Doss said.

Jason Doss, another attorney on the case, called it a “pattern of deception” on the part of Anthem. The firm believes thousands of Georgians may be impacted by the marketing.

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