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Any Willing Provider Law Applies to Provider Network, But Not to HMO

Any Willing Provider Law Applies to Provider Network, But Not to HMO


ERISA and Life Insurance News
(August 21, 2012)

In connection with a dispute between Northeast Georgia Cancer Care, a medical care provider, and two Blue Cross entities, the Georgia Insurance Commissioner concluded that the state’s “Any Willing Provider” (“AWP”) statute applied to both a preferred provider arrangement and a health maintenance organization.

Blue Cross appealed the Commissioner’s administrative findings to the Superior Court of Fulton County – the trial court with jurisdiction over such appeals – and that court reversed both rulings. The Commissioner then appealed to the Georgia Court of Appeals.

The appellate court first held that the Commissioner had correctly determined that the AWP statute applied to the preferred provider network. The Blue Cross entity maintaining the PPO network was licensed as a “health care corporation” under Chapter 20 of the Insurance Code, and such corporations are authorized by the Code to administer “health care plans.” The AWP statute is part of Chapter 20 and, according to the court, “expressly applies to health care corporations.”

Moreover, the PPO network was not a separate entity that fell outside the ambit of the AWP statute. There is “nothing in Chapter 20,” the court held, “to suggest that its provisions, including the AWP statute, do not apply to preferred provider arrangements operated by Chapter 20 health care corporations.”

Nor was the position of Blue Cross aided by another statute, O.C.G.A. § 33-30-25, which allows health care insurers to “place reasonable limits on the number of classes of preferred providers,” so long as they do not discriminate on the basis of factors such as race or religion. The remainder of that statute required “approval of the Commissioner” and, in addition, required that any health care provider that met the standards of the health insurer be given an opportunity to become a preferred provider.

The court rejected, however, the Commissioner’s application of the AWP law to the health maintenance organization. HMOs are governed by Chapter 21 of the Insurance Code, and “other provisions of the Insurance Code, such as the AWP statute, are applicable to HMOs only ‘[e]xcept as otherwise provided by law’ and only if they are ‘not in conflict with [Chapter 21],’” the court wrote. No such caveat applied to the Act governing preferred provider arrangements.

The AWP is inapplicable to for-profit corporations which are not also statutorily defined as “surviving corporations,” the court wrote. A “surviving corporation” was defined as a “health care corporation” which met certain other conditions. The Blue Cross HMO had always existed as a for-profit entity, it was not a “health care corporation,” and it did not fall within the statutory definition of a “surviving corporation.” As a result, the AWP did not apply to the HMO network established by the for-profit Blue Cross HMO.

Click here to view the full August 2012 Edition of the ERISA and Life Insurance News.

Authors
H. Sanders Carter
T (404) 962-1015
F (404) 962-1220
Kenton J. Coppage
T (404) 962-1065
F (404) 962-1256
Dorothy H. Cornwell
T (404) 962-1096
F (404) 962-1246
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