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This is what's causing the fight between Anthem, Northeast Georgia Health System
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The patient drop-off area at the Northeast Georgia Medical Center's emergency room in Gainesville, pictured Oct. 17, 2019. - photo by Scott Rogers

A dispute between Northeast Georgia Health System and Anthem Blue Cross and Blue Shield boils down to who has the final say about what kind of medical care patients need.

Disagreements about what kind of services should be covered have been ongoing for years, leading the health system to file a lawsuit in 2017 against the insurance group.

Those same issues came to a head as the contract between the two was set to expire at the end of September.

The system has now been out of network with the insurer since Oct. 1, leaving thousands across Northeast Georgia uncertain about how best to obtain their health care.

About these stories

The Times has been following the dispute between the Northeast Georgia Health System and Anthem Blue Cross and Blue Shield, speaking with hospital officials and Anthem representatives since before the hospital went out of network with the insurer Oct. 1. As open enrollment deadlines begin hitting, The Times pursued stories from those in the community who are affected by the stalemate. Meanwhile, reporters followed up with the health system, including a meeting with its key leaders and numerous follow-up conversations about what is happening and why. The Times also dug into lawsuits between the two that pinpoint some of their major disagreements over medical coverage.

Steve McNeilly, vice president of managed care for the health system, said Anthem has asked for the ability to change what it covers on short notice.

“Changing the rules creates instability,” McNeilly said. “So what this means for patients is, you could come into the hospital and have a service covered one month and three months later you could come back for the same service and Anthem has changed the rules and will now deem that either not medically necessary or not covered.”

Anthem denies coverage or offers lower payments to the tune of about $6 million a quarter, McNeilly said. NGHS could lose more if it agrees to some terms Anthem is suggesting, he said.

She was unable to swallow and had food and saliva coming back up. The (emergency department) physician noted that the medicine they typically give to alleviate patient symptoms was not going to work, so she got transferred to the (gastrointestinal) lab for additional treatment. After the fact, Anthem denied that as not medically necessary
Steve McNeilly, vice president of managed care, NGHS

Since 2017, the two have been battling in the courts over policy changes related to imaging services and denying emergency department coverage after a patient has already visited the hospital.

The first complaint came in Nov. 1, 2017, when NGHS and Northeast Georgia Physicians Group filed against the insurance groups in Fulton County Superior Court.

“Pursuant to the imaging policy, Blue Cross is redefining certain diagnostic imaging procedures that it now considers to be ‘advanced’ and that it has reimbursed for years in a hospital outpatient setting to be ‘medically necessary’ only in very narrow circumstances,” according to the court filing.

An Anthem representative did not respond to a request for comment from The Times this week. 

Simultaneously, NGHS public relations director Sean Couch said the health system filed for injunctions to “shield our patients from these policies that are unfair.”

The hospital claimed Anthem’s policy dictated where a patient could go for imaging services and that the policy would drive them away from NGMC. 

Couch said free-standing imaging centers often provide lower quality scans and may have fewer trained physicians available to read the scans in a timely manner. He mentioned one case where a patient using a free-standing imaging center was not informed of a brain tumor detected on the scan.

“As a result, diagnosis was delayed and the patient wasn’t aware of the tumor until eight weeks later. If the patient had come to NGMC, the care would have been better coordinated — from imaging, to diagnosis, to talking with the patient,” Couch wrote in an email.

A consent order bars Anthem from implementing its imaging center policy. An injunction was denied regarding an emergency department policy put in place by the insurer in 2017, meaning that policy is in effect.

Anthem covers emergency services that a “prudent layperson” would deem to be a medical emergency, and McNeilly said the term “prudent layperson” has been a point of disagreement.

The American College of Emergency Physicians filed a lawsuit in July 2018 individually and on behalf of the Medical Association of Georgia against Anthem after a mid-2017 correspondence to the insured people in Georgia, Missouri and Kentucky.

“The correspondence stated that the insured patients should ‘save the ER for emergencies — or you’ll be responsible for the cost’ and ‘starting June 1, 2017 [in Missouri and Kentucky, July 1, 2017 in Georgia], you’ll be responsible for ER costs when it’s NOT an emergency,’” according to the complaint.

The insurer makes those determinations using a process that includes checking diagnoses codes, circumstances around the visit and finally having a board-certified medical director to conduct a review “from the perspective of a prudent layperson.” 

“If the medical director determines that a prudent layperson reasonably would believe that he or she was experiencing an emergency medical condition, then the claim is approved and paid under the terms of the membership agreement,” according to court documents.

McNeilly said the health system has faced several cases of patients having coverage denied after seeking emergency treatment.

“We see people coming through the emergency room with what they believe to be a life-threatening emergency, we render service, the patient goes home and Anthem will tell us, in some cases months after the services rendered, that they did not believe the services were medically necessary, it should have been done in urgent care or primary care, and they will deny the payment,” he said.

McNeilly said one patient came to the emergency room with an obstruction in her throat after accidentally swallowing a pork chop bone.

“She was unable to swallow and had food and saliva coming back up. The (emergency department) physician noted that the medicine they typically give to alleviate patient symptoms was not going to work, so she got transferred to the (gastrointestinal) lab for additional treatment,” McNeilly said. “After the fact, Anthem denied that as not medically necessary.”

Another patient came to the emergency room after a car accident. She rated her pain eight on a scale of 10, and a doctor noticed that she had an abnormal rapid heartbeat and was concerned she could be injured.

“Luckily, the patient was able to go home and did not have injury, but after the fact, Anthem said that that ED visit was not medically necessary,” McNeilly said.

NGHS’ executive director of managed care operations Julie Saxton claimed during the injunction battle she had found 200 Blue Cross member claims denied since the insurer changed the policy in 2017.

The hospital didn’t, however, produce data about if the claims were from Anthem members “with individual commercial health plans and thus subject to the (emergency department) review,” according to the order denying the injunction.

“The change could cause a patient to avoid getting needed emergency care, because they’re afraid the care might not be covered,” Couch wrote in an email.

More recently, in April, a “system glitch” caused Anthem to process claims as if they were out of network, Couch said.

Couch said checks were being mailed to patients instead of to the hospital “sometimes worth $35,000 or more.”

“That put a burden on patients to then send the money to NGMC, which many people either didn’t understand or simply didn’t do,” Couch wrote in an email.

This glitch led to $1.25 million in payments not received by NGMC.

The health system is continuing to treat Anthem patients as if they are in network through the end of the year as open enrollment continues for many. That move is costing the hospital about $10 million a month, hospital officials have said.