NORTHEAST GEORGIA CANCER CARE v. Blue Cross
315 Ga. App. 521
| Ga. Ct. App. | 2012Background
- Blue Cross and Blue Shield of Georgia (Blue Cross) operates a PPO; BC Healthcare operates an HMO; both are health care plans under Georgia Insurance Code Chapter 20.
- In 1996 Blue Cross became a for-profit health care corporation and later distributed BC Healthcare as a subsidiary affiliate; BC Healthcare operates an HMO network.
- Northeast Georgia Cancer Care, LLC (Northeast) terminated contracts with Blue Cross and BC Healthcare in 2007; dispute over access to PPO/HMO networks persisted.
- Northeast sought declaratory relief that it could participate in Blue Cross’s PPO and BC Healthcare’s HMO under OCGA § 33-20-16 (Any Willing Provider, AWP).
- The Commissioner held that AWP applied to Blue Cross’s PPO and BC Healthcare’s HMO; the superior court reversed, and the Court of Appeals granted discretionary review.
- The Court of Appeals ultimately held that AWP applies to Blue Cross’s PPO but not to BC Healthcare’s HMO; case remanded for further proceedings consistent with this opinion.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Does the AWP statute apply to Blue Cross's PPO? | Northeast: AWP applies to all health care plans under Chapter 20. | Blue Cross: Chapter 30 PPOs allow limits; AWP conflicts with 33-30-25 and does not apply. | AWP applies to Blue Cross's PPO. |
| Does the AWP statute apply to BC Healthcare's HMO network? | Northeast: AWP should apply due to control by Blue Cross/affiliate and lack of specific exemption. | BC Healthcare is not a Chapter 20 health care corporation; AWP not applicable under OCGA 33-21-28(a); and surviving/affiliate status not shown. | AWP does not apply to BC Healthcare's HMO network. |
Key Cases Cited
- Pruitt Corp. v. Georgia Dept. of Community Health, 284 Ga. 158 (2008) (statutory review standards for agency decisions)
- Northeast Ga. Cancer Care, LLC v. Blue Cross & Blue Shield of Ga., 297 Ga.App. 28 (2009) (administrative exhaustion under OCGA § 33-20-30)
- Ramos-Silva v. State Farm Mut. Ins. Co., 300 Ga.App. 699 (2009) (in pari materia interpretation of related statutes)
- Glinton v. R, 271 Ga. 864 (1999) (specific statutes prevail over general statutes; in pari materia)
- Ga. Dept. of Transp. v. Evans, 269 Ga. 400 (1998) (statutory interpretation principles and legislative intent)