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HMO partnership ends

By Ed Brock

Getting healthcare will be a little less convenient for Clayton County Water Authority employees and others who use Blue Cross and Blue Shield of Georgia insurance.

Negotiations over an HMO/POS network contract between Promina Health System, the company that owns Southern Regional Medical Center in Riverdale, and Blue Cross, one of the state's largest insurance providers, collapsed this week.

That means Blue Cross will require its customers who are seeing doctors in the Promina network to switch to another doctor by Aug. 31.

"In general it will certainly affect the convenience some of our employees have of having a Blue Cross hospital in the area," said Ed Durham, human resources director for the Water Authority.

The authority has 350 employees, Durham said.

Promina officials say the breakdown in negotiations occurred because WellPoint, the company that owns Blue Cross, did not want to admit Promina doctors into their network because they would compete with doctors in the WellPoint network. Blue Cross officials say that's not the problem.

"The problem is that the rates they are demanding are so over the Atlanta market that it calls into question if we could pay their rates," said Charlie Harman, spokesman for Blue Cross.

Harman said Blue Cross is not taking away their customers' choice because they still have 1,100 primary care physicians at 36 hospitals, including the Henry County Medical Center, for the customers to chose from along with 3,600 specialists.

The issue of rates had already been settled in the negotiations, Southern Regional Health Systems President and CEO Ed Bonn said. The negotiations failed because Promina felt that Blue Cross was trying to steer customers to their own specialists.

Another problem Promina has with Blue Cross, Bonn said, is what they consider excessive denials of claims by the company. Blue Cross' denial rate is 40 percent higher than other insurance companies they deal with, Bonn said, and those denials are often made for pre-approved treatments by citing administrative omissions in the filing.

Harman said the company's denial rate is less than 2 or 3 percent. He also said Promina is trying to run the health care plan when they should be caring for the patients.

Bonn said obstetrical (maternity) patients would be most affected by the need to switch doctors. Also, while Blue Cross customers are still covered for emergency medical work, if they have to be admitted for acute care they would have to be transferred to another facility.

Bonn also pointed out that Blue Cross customers could stay with their current Promina physician and pay out-of-network rates.

If Blue Cross members don't pick another physician by Sept. 15 one will be selected for them and that assignment will become effective on Oct. 1, according to Harman.

Bonn said the negotiations are not completely finished as far as Promina is concerned.

"We're still sitting at the table waiting for them to come back," Bonn said.

"If they'll be serious we'll meet with them," Harman said. "Their last offer was not a serious offer."