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November 07. 2013 10:09PM

Rochester hospital threatens lawsuit over Blue Cross Blue Shield, ACA decisions

CONCORD — The president of Frisbie Memorial Hospital in Rochester is threatening legal action against the state because the hospital is not included in the provider network established by the only health insurance carrier selling policies on the state health exchange.

"The door to Obamacare was slammed shut and we are blocked from participating," said Al Felgar, Frisbie's chief executive officer. "This not only drives a wedge between our physicians and the thousands of patients we serve, this decision jeopardizes our future operations as a hospital serving greater Rochester."

Frisbie is one of nine hospitals and their physician practices not included in the Pathway network established by Anthem Blue Cross Blue Shield NH for policies offered on the exchange, a key provision of the Affordable Care Act.

Anthem has repeatedly said it established the narrow provider network to make premium costs affordable and contends its network of 16 of the state's 26 hospitals meets all state requirements. The network includes about 75 percent of all primary care doctors and 85 percent of specialists, company officials said earlier this week.

Frisbie and other hospitals claim either Anthem never contacted them or Anthem offered a low reimbursement rate, and they were told to take it or leave it. The rates were similar to Medicare rates or about 100 percent of costs, according to several hospitals.

Felgar said Thursday morning that the first step is to ask Insurance Commissioner Roger Sevigny for a rehearing about Anthem's failure to include Frisbie and other hospitals in its network and for information about how those determinations were made by the carrier.

Felgar said he expects Sevigny to deny his request at which point, Frisbie intends to sue the department. The suit will be filed in Stafford County Superior Court.

"I'm quite baffled why a low-cost provider and a high-quality producer is not even invited to sit down and negotiate with Anthem on this very important subject, Felgar said. "I want to know what is going on. I want a chance to get in to the game."

He said the ACA represents the biggest change in health care in the country's history and every hospital should have the opportunity to participate. Frisbie is being denied that opportunity and that is a hardship for both its patients and the hospital, he said.

"The state had a responsibility on the biggest health reform bill ever passed in this country to have an open process," Felgar said. "Nobody's taking responsibility. The feds point to the state and the state points to the feds."

He touted several studies and reports indicating Frisbie costs and care are on par or better than other regional hospitals and wonders why Anthem would not even discuss joining its network.

Frisbie treated about 7,000 patients a year for free, Felgar noted. Now that they will have insurance to pay for their services, the hospital cannot participate, he said.

Sevigny has said his department's limited authority in approving exchange insurers and their policies is to ensure they meet state network and other requirements. He said Anthem's policies and network did meet state requirements.

Anthem was the only company to apply to offer policies on the exchange, although Delta Dental is offering dental insurance. At least one other insurers is expected to join the exchange next year.

State and federal officials approved Anthem's plans including the smaller Pathway network.

grayno@unionleader.com


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