Anthem Blue Cross faces charge of violating "Any Willing Provider" law

A California doctor has filed a lawsuit against Anthem Blue Cross for allegedly denying his application to become a part of the company's provider network, an action the lawsuit contends violates California's "Any Willing Provider" law.

The lawsuit seeks to enjoin Blue Cross from preventing any physician who is willing to accept the terms of Blue Cross contracts and meets Blue Cross' eligibility criteria from becoming a Blue Cross provider.

The legal action revives an issue that was contested numerous times in the early 2000s, when HMOs and MCOs had established a practice of limiting the number of doctors in their provider networks as a cost-saving measure, and could bring back into focus individual states' rights surrounding insurance regulation.

So-called "Any Willing Provider" laws, on the books in most states, require insurance plans to accept any qualified provider who is willing to accept the terms and conditions of a managed care plan. Health plans are not forced to accept any physician, but the company must clearly state its criteria for selection as a provider.

Jeffrey Nordella, the medical director of Porter Ranch Quality Care in Northridge, Calif., filed the lawsuit after Blue Cross denied his application to become a participating provider. According to the complaint, Nordella met Blue Cross' eligibility criteria, had previously been a participating Blue Cross provider and was willing to accept the terms of Blue Cross' provider contracts. Blue Cross informed Nordella there was "no network need established in the area of his practice."

"Patients should have more doctors in their health networks, not fewer, because this means more choice and better health care for patients," said Nordella.

The lawsuit revives old battle lines drawn by physicians, physician groups and insurance companies over AWP laws. In 2003, the United States Supreme Court upheld such a law in Kentucky.

At that time, the insurance industry contended that federal law under The Employee Retirement Income Security Act of 1974 (ERISA) should supercede AWP laws enacted at state level. The court upheld Kentucky's law, a decision that has given states greater power in their ability to regulate insurance providers.

The current legal action against Anthem Blue Cross once again puts the spotlight on what many see as competing objectives: the physicians' desire to provide a large, diverse and well-distributed network of doctors, which they say improves quality of care, and the insurance companies' desire to limit the number of doctors in its network as a cost control measure.