The world of health insurance is like a spider web woven by five main companies, but just how providers of choice work within that web leaves some consumers feeling ensnared.
That’s been emphasized lately with a stalemate between the Gainesville-based Northeast Georgia Health System and Anthem Blue Cross and Blue Shield.
Even though the contract expired Oct. 1, the health system will continue to treat patients with Anthem insurance as if they are in-network until Dec. 31.
The hospital is still on solid footing with the other four major providers — Aetna, Cigna, Humana and UnitedHealthcare.
“We have taken the opportunity during this down time, for the last month, to extend our contracts with Cigna and Aetna for multiple years,” said Steve McNeilly, vice president of managed care for the health system. “They’ve agreed to similar rates and terms that we offered Anthem, and they are three-plus-year contracts.”
The hospital has an “evergreen provision” with Humana, meaning the contract automatically renews every 12 months “unless either party wishes to renegotiate,” McNeilly said. “And if so, they have to provide proper notice.”
Lives on the line
This special weeklong series explores how cost and bureaucracy stand between local residents and their health care. Times reporters pored through the latest Community Needs Health Assessment, conducted numerous interviews with those in the local health care industry and those affected by it and examined the latest efforts by state government and politicians to remedy problems in our health care system. Read other stories in the series at gainesvilletimes.com/livesontheline. And here's a list of 7 Hall County medical offices and the insurers they accept.
UnitedHealthcare has to inform the hospital by Aug. 1 every year if it wants to renegotiate its contract. The way things stand now, “the next time they could start (talks) would be Aug. 1, 2020 … so that contract is pretty much secure through April 2021,” McNeilly said.
But here’s where things get really complicated — and a key thing for patients to be mindful of, especially if they’re considering elective surgery.
There are independent medical groups — emergency department doctors, anesthesiologists, radiologists and pathologists — that serve patients at the hospital but aren’t affiliated with the health system.
“As a result, they negotiate their own contracts,” McNeilly said. “We meet with them routinely, no less than annually to talk about contracts that we’re a part of. We encourage them to be in network with all of the contracts that the (hospital) is part of, but from time to time, they do get out of network.”
So, even though the emergency room is part of the hospital, it is operated by one of those medical groups, Georgia Emergency Department Services, which has a list of insurance plans it accepts. In the case of the ER, the emergency room is in-network for Anthem customers but out-of-network for UnitedHealthcare.
"We continue to work in good faith with United Healthcare to reach an agreement that allows us to retain and recruit the level of board-certified physicians needed to provide the expert, life-saving emergency and trauma care this community relies on,” said Dr. Mohak Davé, chief of Emergency Medicine for Northeast Georgia Medical Center.
“We are advising patients to send us the explanation of benefit document United sends them for each ER visit,” Davé said. “In most cases, we only ask patients to pay the correct deductible and copay amounts, not the full balance of the bill.”
If patients still have Anthem past Dec. 31 and a contract still hasn’t been worked out with the health system, they can still receive in-network care in Hall County, depending on what kind of care they need.
Longstreet Clinic, which has offices in Gainesville and Oakwood, as well as outside Hall County, accepts Anthem.
The hospital’s stalemate with Anthem has made things “very difficult” at Longstreet, said Mimi Collins, Longstreet CEO.
“A significant number of Longstreet providers also provide services at Northeast Georgia Medical Center, and that might be the only hospital provider they practice in,” Collins said.
Northside Hospital, which has hospitals throughout metro Atlanta, has pushed into Hall County with outpatient and doctor’s offices, including Northeast Georgia Diagnostic Clinic and the recently opened Arthritis & Total Joint Specialists. It also accepts Anthem.
However, some insurance providers in network at Northside may not be accepted at all its outpatient clinics and doctor’s offices, spokeswoman Katherine Watson said.
“We encourage patients to call their insurance provider ahead of any appointments or procedures to confirm their specific coverage,” she said.
Medlink Georgia, a nonprofit health care center that provides basic services and has an office in Gainesville, accepts Aetna, Alliant, Cigna, Humana and UnitedHealthcare, as well as Medicaid and Medicare, according to its website.
Consumers typically have insurance through employer-sponsored plans, but can buy them privately on the open market. Or they buy plans through healthcare.gov, the federal exchange set up by the Patient Protection and Affordable Care Act, commonly referred to as ACA.