Georgia Blues plan sued under any-willing-provider law

The health plan says the statute requiring open networks does not apply to HMOs.

By Amy Lynn Sorrel — Posted Feb. 18, 2008

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Georgia physicians are fighting what they say is an illegal attempt by the state Blues to shut some doctors out of the health plan's HMO network in violation of the state's so-called any-willing-provider law.

Most states have such laws, which generally prohibit managed care entities from excluding doctors from their panels as long as the physicians meet the plan's criteria and are willing to accept its terms. But doctors say BlueCross BlueShield of Georgia's refusal to include some of Northeast Georgia Cancer Care LLC's oncologists in its HMO plan is putting patient care at stake.

Northeast Georgia Cancer Care sued the Blues after the company told doctors its medical oncology network was closed while it gave an exclusive HMO contract to another cancer group for those services in the Athens, Ga., market. Both sides were renegotiating after settling a separate contract dispute, which remains confidential. The Blues maintained its HMO and PPO contracts with Northeast's radiology oncologists but allowed only the medical oncologists back into its PPO plan.

As a result, more than 100 of Northeast Georgia Cancer Care's patients lost their long-time doctors and now are forced to drive hours away for care, said oncologist Mark Vrana, MD, the group's managing physician.

"We can't take care of our patients the way we've been taking care of them for years," Dr. Vrana said. His practice has satellite clinics serving more than 30 northeast Georgia counties in the largely rural area, and he said he often travels more than 60 miles to treat patients who otherwise would have no access to care.

Meanwhile, the Blues said the any-willing-provider statute does not apply to HMOs and is asking the Athens-Clarke County Superior Court to dismiss the doctors' lawsuit.

State doctors contest that claim.

The Medical Assn. of Georgia, in a friend-of-the-court brief it filed last December, said the any-willing-provider statute was intended to prevent the kind of disruption in physician-patient relationships that Northeast Georgia Cancer Care patients are facing because of the Blues' exclusionary actions.

MAG General Counsel Donald Palmisano Jr. said the purpose of the law is to "make sure patients had access to quality medical services regardless of where they live and to ensure continuity of care" with the doctor of their choice.

He said many patients cannot afford more expensive out-of-network options. The statute was one way to stop managed care entities, including HMOs, from closing their panels to avoid higher costs, and penalizing patients as a result, Palmisano said.

Georgia doctors are not alone in their fight.

New York lawmakers recently introduced legislation that would prohibit HMOs from discriminating against physicians under its any-willing-provider statute, according to American Medical Association research.

"Health insurers have an enormous financial incentive to remove sick people from their rolls, and one way to accomplish that is to make it difficult for them to access the physicians and services they need," said AMA House of Delegates Speaker Jeremy A. Lazarus, MD. "The AMA has repeatedly emphasized that it is essential for health insurers to maintain adequate physician networks that include the resources necessary for patients with serious illnesses."

Blues challenges law

But the Blues said Georgia law gives HMOs the discretion to staff their panels appropriately. The insurer also said the dispute is one for state insurance regulators to decide, not the courts.

"Georgia law sets the proper balance between the rights of BlueCross BlueShield of Georgia -- and all HMOs -- to maintain the integrity of provider networks and the rights of Georgia citizens to access care," said BlueCross BlueShield of Georgia spokeswoman Cynthia L. Sanders.

The health plan argued in court documents that applying the any-willing-provider statute to an HMO "would make no economic sense" because the fundamental purpose of the network is to obtain reasonable reimbursement rates from doctors in exchange for giving them a "relatively exclusive opportunity" to provide their services to members.

Sanders said it was Northeast Georgia Cancer Care's decision to drop out of its HMO plan, leaving patients without access to in-network oncologists in their immediate community.

"In order to ensure our members would have uninterrupted access ... BlueCross BlueShield of Georgia took immediate action to expand and stabilize its provider network" by contracting with another cancer group, Sanders said.

Northeast Georgia Cancer Care said it did not drop out of the Blues network but was forced out in retaliation for the earlier contract dispute. The MAG in its court brief did not weigh in on that issue.

Still, MAG's Palmisano said the case marks the first time a Georgia court will address the scope of the any-willing-provider statute. No hearing date has been set.

But because the Blues is the largest health plan in the state, doctors are concerned that the outcome of the case could affect patient care widely, he said.

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Case at a glance

Are HMOs exempt from a Georgia insurance law?

A Georgia trial court will decide.

Impact: Doctors say the law was meant to protect against managed care abuses and ensure patient choice and access to care. BlueCross BlueShield of Georgia says HMOs must have the ability to staff their networks appropriately.

Northeast Georgia Cancer Care LLC v. BlueCross BlueShield of Georgia, Athens-Clarke County Superior Court, Georgia

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