Judge extends order, keeping Northside patients in Anthem network until spring

Last spring, she was diagnosed with very aggressive stage 4 breast cancer that had metastasized to her bones. Since then, she has been receiving ongoing care — surgeries, diagnostics, chemotherapy, treatments for knock-on conditions — from Northside and doctors in her system.

Legend

Arlene Sinanian has spent 2021 and 2022 coping with a stage four cancer diagnosis and concurrently, the bureaucratic nightmare of a contract dispute between her insurance company, Anthem Blue Cross Blue Shield, and Northside Hospital, whose doctors and facilities provide him with cancer care. Sinanian, from Atlanta, is shown here in a photo for her pet business, Pupcakes Playcare.

Credit: document

Arlene Sinanian has spent 2021 and 2022 coping with a stage four cancer diagnosis and concurrently, the bureaucratic nightmare of a contract dispute between her insurance company, Anthem Blue Cross Blue Shield, and Northside Hospital, whose doctors and facilities provide him with cancer care.  Sinanian, from Atlanta, is shown here in a photo for her pet business, Pupcakes Playcare.

Credit: document

callout arrowLegend

Arlene Sinanian has spent 2021 and 2022 coping with a stage four cancer diagnosis and concurrently, the bureaucratic nightmare of a contract dispute between her insurance company, Anthem Blue Cross Blue Shield, and Northside Hospital, whose doctors and facilities provide him with cancer care. Sinanian, from Atlanta, is shown here in a photo for her pet business, Pupcakes Playcare.

Credit: document

Credit: document

Shortly after renewing her Anthem policy last fall, she learned of the impending contract dispute. At that time, the deadline for termination of the contract was December 31. He was told that Anthem would grant him a “continuity of care” exemption allowing him to remain with his carers at Northside if the contract expired. She filled out the form.

But the approval didn’t happen right away and her doctors started telling her they couldn’t schedule her. Sinanian began calling Anthem representatives regularly. She reports being transferred, disconnected, being given incorrect information, finally being told she would be helped, then being told it wasn’t true.

As the contract termination deadline approached, she was at her wit’s end. “Here it’s Friday, I have to go to chemo [Monday] and I don’t think I can afford it. I know I can’t afford it. I should sell my house and use all the savings I had. On a Friday, the last possible day, Anthem told her that the Continuity of Care request had been approved. His doctors gave him chemotherapy scheduled for the following Monday.

But the nightmare was not over. Anthem has assigned her a new primary care physician an hour away who should find out about her and her treatment regimen.

“The stress level was unbelievable for me,” Sinanian said.

In years past, these disputes between the insurer and the hospital system over reimbursement rates were usually resolved before an agreement was terminated. But recently, more and more contracts have expired, sending anxious patients uncertain about whether to stay with a medical provider but face higher costs.

Wellstar Health System, based in Marietta, has been out of network for UnitedHealthcare members since early October. It affected about 80,000 patients, Wellstar said on Friday. All hospitals in Cobb County are Wellstar facilities.

Health care experts examining the Northside/Anthem dispute say both sides need each other and will eventually come to an agreement.

The anthem is the metro Atlanta market’s heavyweight health insurer, while the Northside system includes an Atlanta hospital that, according to its leaders, delivers more babies than any other community hospital in the country – more than 15,000 a year. Not having Northside in its network would leave a huge hole in Anthem’s local network.

However, it is unusual for a contract dispute to be played out in court. At the heart of the court case is a new state law that went into effect in July. House Bill 454 includes a provision that during a public health emergency such as a pandemic, an insurer is prohibited from terminating a contract with a medical provider.

Anthem argues that the law is unconstitutional.

Cherokee County recently stepped in as an additional plaintiff supporting Northside’s position. Cherokee, a northern suburb of Atlanta, noted that Northside operates the only hospital in the county.

Gwinnett County, the state’s second most populous, filed a similar petition.

Josh Berlin, an Atlanta health care consultant, said Anthem patients grew increasingly frustrated as they tried to resolve the tangle of legal and contractual issues.

“It’s hard enough to understand the complexity of healthcare today, but add to that the influx of COVID patients insured by Anthem in Northside, and it complicates things even further.”

Northside said in a statement late Friday that he “is acutely aware of the stress and frustration of Anthem members and their families.”

The statement said Northside is seeking an agreement that “provides the best benefits for patients and their families.”

Anthem said in a statement on Saturday that “we have made Northside a fair and reasonable proposal with generous raises.”

“It is important that we work together to finalize a new agreement that aims to increase accessibility by protecting affordability and ensuring quality.”

Sinanian created a Facebook group for other patients caught up in the conflict. It has about 100 members now, she said.

She fears the row and resulting uncertainty could lead to stress that could have delayed her recovery – a possibility her doctors have warned her about.

Patients like her, trapped in the contract dispute, are “fundamentally helpless”, she said.

Andy Miller is editor of Georgia Health News.

Comments are closed.