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Georgia doctors must be allowed to join Blues HMO

The state insurance department has ruled that Georgia's any-willing-provider law applies to managed care groups.

By Victoria Stagg Elliott — Posted April 30, 2010

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Blue Cross Blue Shield Healthcare Plan of Georgia must allow Northeast Georgia Cancer Care of Athens to participate in its health maintenance organization network, according to statements issued April 7 by the state's Dept. of Insurance.

"I'm sure consumers want to see more doctors in their health networks, not fewer," said Insurance Commissioner John W. Oxendine. "More doctors mean more choice for patients, and I think it's clear that's the intent of the any-willing-provider law."

The state's any-willing-provider law, much like those in many other states, grants doctors and health care providers licensed to practice and in good standing the right to become health insurance participants. But the law did not necessarily require an HMO to take in any physician who wanted to join it. Oxendine's ruling was the first time a regulator said it did.

The ruling does not necessarily include all HMOs in the state, but the commissioner reserves the right to extend it in the future. Blue Cross Blue Shield Healthcare Plan of Georgia, owned by WellPoint, has until the first week of May to appeal the ruling.

But Oxendine's decision, while specific to the Blues plan, is expected to have a major impact on doctors in Georgia because of the plan's prominence.

"This was a huge victory for patients and physicians in Georgia, because the networks will no longer be allowed to disrupt the patient-physician relationship or to impede a patient's continuity of care," said Donald J. Palmisano Jr., the Medical Assn. of Georgia's general counsel and director of government relations.

A statement issued by the insurer read: "This decision significantly expands Georgia's any-willing-provider statute and is an interpretation that does not reflect the language of the statute or the intent of the General Assembly. We are currently evaluating the legal implications of the DOI's decision and are assessing what next steps are appropriate."

Northeast Georgia Cancer Care sued June 11, 2007, in response to a contract dispute that blocked its participation in this HMO, although the practice continued to take part in the PPO. The Athens-Clarke County Superior Court initially granted the insurer's motion for dismissal and declared that the dispute did not fall under the any-willing-provider law. MAG had filed a friend-of-the-court brief as part of the 2007 proceedings.

A filing with the insurance commissioner near the end of 2009 ensued.

Physicians with the practice are now waiting for a contract that will allow them to care for HMO patients.

"Because of us being excluded from the network, some of our patients had to drive a hundred miles to see an oncologist," said oncologist Mark Vrana, MD, a managing partner of the group. "We want to get back in the network and then we would be very happy to take care of these patients if they want to see us."

American Medical Association policy acknowledges that health care plans and networks may develop criteria to determine the number, geographic distribution and specialties of physicians needed. The AMA advocates that this criteria be disclosed to physicians and routinely evaluated for the impact on quality, access, cost and patient choice.

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