Piedmont hospitals sue Blue Cross over testing

New limits on ER visits, imaging a risk to patients, critics say.

A major Georgia hospital group has sued Blue Cross Blue Shield of Georgia and its parent company, accusing it of “a national scheme” to save money at the expense of patient safety.

Last fall, the lawsuit states, Blue Cross Blue Shield of Georgia stopped paying when some of its outpatient policyholders undergo imaging, such as MRIs and CAT scans, in hospitals rather than in cheaper free-standing centers. And last summer, The Atlanta Journal-Constitution reported, the insurer sent letters to policyholders saying that it would no longer pay if they went to the emergency room without a good enough reason. Those patients get stuck with the whole bill, and sometimes they can’t pay.

Piedmont Hospital and five sister facilities say the new policies also hurt patients. They have sued Blue Cross and its Indianapolis-based parent company, Anthem Inc.

Saying the changes are a breach of their contract and an impediment to necessary health care, the hos- pital group accuses Anthem of “a national scheme” to impose policies “that, over time, intentionally deteri- orate coverage for policy- holders.”

“These two policies are motivated solely by Anthem’s desire to reduce its costs, regardless of the policies’ harmful consequences on access to medically necessary services, clinical inte- gration, patient safety, and quality of care,” Piedmont wrote in its complaint to the court.

A spokesman for Anthem, Colin Manning, said the company had not yet filed a response and would not comment.

When Blue Cross told patients last summer that it would not reimburse costs for ER visits that Blue Cross finds unnecessary, it insisted that it would not deny coverage if it didn’t turn out to be an emergency, as long the patient had good reason to believe it was.

A spokesman for Pied- mont, Matt Gove, said that’s not what’s happening. He said the hospitals had provided 75 examples to their lawyers of cases where coverage had been denied when it shouldn’t have.

As for Blue Cross’ pol- icy on radiology, Pied- mont claims that independent imaging centers can delay and harm patient care because the quality may not be as good. The patient must bring back the images to the doctor on a disk, which is “often” corrupted and unreadable, according to the suit. It adds that the process imposes a delay on care and also deprives the patient of the benefit of having the images read by specialist the hospital would have on site, as opposed to general radiol- ogists typically employed by imaging centers. Adding salt to the wound for patients, Piedmont said, Blue Cross isn’t adequately informing patients. So they see Piedmont as in network, but they don’t realize its imaging services may not be, perhaps until it’s too late. Blue Cross allows several exemptions for the imag- ing policy. They include if the patient requires seda- tion and the nearby imaging center can’t provide that; if the particular services are only available in the hospital; and if the patient is under 10 years old. A Gainesville hospital also sued Blue Cross over its imaging policy, though it says it has not yet seen the policy go into effect. In fact, after it sued, Blue Cross added more exemptions to the policy. That wasn’t enough, hospital execu- tives say. “This is the latest in a series of significant and negative changes Anthem BCBSGA has made to member benefits that erode coverage, dictate medical decisions and interfere with patient-physician relation- ships,” Steven McNeilly, the vice president of managed care for Northeast Georgia Health System, said in an emailed statement. “Our lawsuit has delayed the pol- icy from going into effect for our patients — and we hope it never will.” Hospitals are constantly trying to beef up profitable services in order to make up for the money they lose on other services, such as emer- gency rooms. Imaging is a profit center. A lobbyist for Georgia’s insurance industry, Graham Thompson, said that’s the real reason hospitals are complaining. “The fact of the matter is we’ve seen mass consolidation where hospitals have bought imaging centers,” Thompson said. “So which side of the fence is more con- cerned about revenue? ... Just slapping a hospital fee on an imaging center, that’s a real challenge for us.” He said asking the patient to go to a less expensive location for the same quality would only benefit the patient in the end. The move to limit emergency room coverage came as Blue Cross was negotiating with the state over whether it could afford to stay in Georgia’s individual market at all. Ethan James, the executive vice president for external affairs at the Georgia Hospital Association, said the policy is “dangerous” across the board. “Because what you’re asking patients to do is self-diagnose whether or not this is an emergency,” he said. “Chest pains could very well be indigestion, but (they) could very well be a heart attack.” Blue Cross insisted it will pay claims for patients who have symptoms that present a valid fear of an emergency, whether or not they turn out to be an emergency. James said the history of insurance company reimbursements shows that’s not always the case. “They’re second-guessing the physician after the diagnosis comes back,” he said. “Meanwhile, the physician is trying to determine, ‘What is the diagnosis, what do we need to diagnose this?’ Then they need to do those tests. For an insurer to come back afterward and say, ‘That’s not appropriate,’ is not only unfair to the provider who performed these services, but it’s also dangerous for the patient because they may not go back the next time they’re presenting with symptoms. And it could be a heart attack.” Thompson represents the insurance industry, not just Blue Cross, but he said people who treat the ER like their personal clinic are a major problem for hospitals statewide. “People should go to the ER when they really need to go to the ER,” Thompson said. “They just want to have people ask the question. ‘Should I show up, is this the most appropriate setting for care?’”