A New Hampshire hospital fighting to get into Anthem's new narrow network says the insurance company submitted an incomplete application to state regulators, who then approved it without the necessary scrutiny.
Frisbie Memorial Hospital in Rochester is one of 10 hospitals excluded from Anthem Blue Cross and Blue Shield's provider network for individual plans being sold under the federal healthcare overhaul law. The state Insurance Department denied Frisbie's request to reconsider its decision, but it released hundreds of documents Anthem submitted and is holding a public hearing Monday to explain its process. It denies the hospital's allegations of wrongdoing, as does Anthem.
Jeremy Eggleton, the hospital's lawyer, said he will argue Monday that the department didn't get the information necessary to fully evaluate the proposed network, and if it had, it wouldn't have approved it.
"Not only is this network inadequate from a procedural point of view — the proper documentation was never submitted — but I would suggest the reason that didn't happen is it's not network adequate as a matter of substance," he said.
Anthem officials have said the main driver in selecting providers was geography — more than 90 percent of the plans' potential customers live within 20 miles of a network hospital, though under state law, that distance could've been twice as far and still considered adequate. They said including all hospitals would have driven up premiums because network hospitals agreed to reimbursement rate concessions in exchange for the promise of a certain volume of patients. The network includes 16 hospitals, 74 percent of the state's primary care providers and 85 percent of specialists.
Anthem spokesman Christopher Dugan said Friday that the company complied with all laws and regulations and met or exceeded the adequacy requirements.
But according to Eggleton, the Insurance Department also was required to ask Anthem to assess which providers are accepting new patients. The documents Anthem submitted, which were also reviewed by The Associated Press, include lists of providers but no information about whether they are accepting new patients.
"If none of those providers are accepting new patients, then that's not a very useful thing for all these new patients who are getting insurance on the exchange," Eggleton said.
The documents include Anthem's analysis of patient access to medical specialties such as oncology, psychiatry and heart surgery. Over the span of several months, it added hospitals and providers to address deficiencies, but there is scant information about why some hospitals made the cut and others did not.
In a June 2013 letter, an Anthem official noted deficiencies in Carroll, Coos and Grafton counties and said the addition of Exeter Hospital, Lakes Region General Hospital and Franklin Regional Hospital would fix two of the problems in Carroll County. That caught Eggleton's eye because Exeter Hospital is in Rockingham County, several counties away from Carroll County.
"It seems very arbitrary to me. The governor lives in Exeter, so there's a possible political motivation there, I suppose," he said. "If you're looking to address network deficiencies in those counties, you wouldn't naturally choose Exeter as a plug."
Insurance Commissioner Roger Sevigny has said that even if the department reversed its decision, it couldn't order Anthem to contract with Frisbie. Jennifer Patterson, the department's attorney, said it will focus Monday on explaining network adequacy standards and how they might need to be changed going forward. She declined to comment on Eggleton's specific complaints but said the department followed proper procedures in approving Anthem's application.
Since that approval, the department has performed market conduct exams to examine the capacity of providers to accept new patients, not network adequacy, Patterson said. The results of that exam were sent to Anthem last week and remain confidential while the company has 30 days to respond.
U.S. Rep. Carol Shea-Porter last week called on Anthem to waive that confidentiality, but the company declined.