Maine Medical Center vows to exit Anthem insurance network because of billing disputes

File Photo / William Hall Maine Medical Center in Portland will exit the Anthem insurance network in 2023, the hospital's parent, MaineHealth, said.

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By Jessica Hall

MaineHealth aired a private billing dispute with insurer Anthem Inc. (NYSE: ANTM) and on Wednesday said Maine's largest hospital, Maine Medical Center, will leave the insurer’s network because it has failed to pay millions of dollars for health care services.

If MaineHealth makes good on its threat, the change would impact those who have Anthem coverage from their employer as well as those who buy insurance directly from Anthem, including through the state-run health care exchange.

“Even though Anthem subscribers will have nine months to prepare, we know that this will affect many of our patients, and we deeply regret having to take this step,” Andrew Mueller, CEO of MaineHealth, said in a statement.

“We will do everything in our power to reduce the impact of this change on our patients, however our relationship with Anthem has reached a point where it is hurting our ability to sustain the level of care our communities have come to expect from MaineHealth and its flagship hospital, Maine Medical Center."

The decision to pull Maine Medical Center out of the Anthem network is based on how the insurer’s practices in recent years have affected the 637-bed hospital and its patients, MaineHealth said. MaineHealth’s seven other hospitals in Maine and one in New Hampshire will continue to be part of the Anthem network.

Anthem owes MaineHealth more than $70 million for health care services dating back over three years, according to MaineHealth. Anthem has also been reducing negotiated payments to Maine Medical Center that should not be in dispute, the health care system said.

While the much-publicized announcement could be a negotiating tactic, it immediately raised concerns throughout the state.

Gov. Janet Mills said she was “deeply concerned” about the potential contract termination.

“Maine Medical Center is the largest tertiary care hospital in Maine and Anthem is the state’s largest insurer, serving more than 300,000 people, including state employees. Termination of the contract would significantly harm the cost of and access to care for Maine people who are Anthem customers, particularly in southern Maine, and seriously impact the operation of the health care market across the state,” Mills said.

“Termination should be avoided at all costs. As both private parties negotiate the contract, I strongly urge them to put the interests of Maine people first, to resolve this issue in a timely way, and to reach an agreement that averts the need for such a drastic, damaging move."

Anthem said MaineHealth's current contract with the insurer goes through Sept. 30, 2024.

"Our expectation is they will honor the contract. There is a long way to go before the end of the year and we expect that MaineHealth will work with us on resolving these issues, resulting in no disruption to members," said Stephanie DuBois, director of public relations for Anthem Blue Cross and Blue Shield in Maine.

"We’ve had a strong working relationship with MaineHealth for many years, but for the last few years we’ve been in discussions with them regarding unilateral increases in charges for health services provided at Maine Medical Center. This has resulted in direct higher costs to our members and all consumers that use Maine Medical Center, which is unacceptable," DuBois said.

"It’s disappointing MaineHealth would choose to alarm consumers by announcing an intention to leave our care provider network when our current contract doesn’t expire for another two years. We have a responsibility to those we serve, and we remain committed to resolving these years-long issues with MaineHealth. We hope they will join us and get back to working on how we can restore affordability at Maine Medical Center.”

Anthem also said that it is not in active contract negotiations with MaineHealth.

MaineHealth, for its part, contends that Anthem has been denying prior authorizations and referrals for needed care, forcing patients and their physicians to appeal or resubmit claims. Last summer, Anthem denied proper reimbursement to in-network providers because it was using incorrect provider identification numbers. As a result, Anthem incorrectly denied claims for 10,000 accounts, MaineHealth said.

While the insurer has said publicly that it is fixing its systems and putting its problems behind it, that has not been the experience of MaineHealth. Last week, the Georgia Office of Insurance and Fire Safety fined Anthem $5 million for practices similar to what MaineHealth has experienced.

“We would not pull Maine Medical Center out of Anthem’s network unless we felt we absolutely had to,” said Mueller. “We have been in discussions, including mediation, with Anthem for several months and have made little progress.”

Anthem said MaineHealth has been "overcharging our members and all Maine Medical Center consumers and this is unacceptable."

Anthem claims the issue goes back at least four years.

During a routine review in 2018, Anthem discovered overbilling by Maine Medical Center for anesthesia and operating room services. Anthem said it worked with MaineHealth to identify the Anthem members impacted by this, and as a result of the investigation, MaineHealth eventually relented and issued refunds to Anthem members for the amount they were overcharged.

These overcharges amounted to nearly $20 million to Anthem members.

MaineHealth said it only plans to remove Maine Medical Center from the Anthem network because the insurer has been focused on that hospital. MaineHealth also hopes that confining the change to Maine Medical Center will minimize the impact on patients covered by Anthem and any disruption in its service area of 11 counties in Maine and Carroll County, N.H.

Leaving the Anthem network would not necessarily prevent patients covered by Anthem from using Maine Medical Center, but insurers typically do not cover care obtained from out-of-network providers at the same level as those that are in-network. Patients often have to pay more out-of-pocket to use a provider out of an insurer’s network.

Under the law, Anthem must continue to fully cover emergency care at Maine Medical Center even without an in-network agreement. And MaineHealth is committed to do what it can to reduce the impact that this change will have to patients covered by Anthem.

For subscribers to Anthem|MaineHealth Medicare Advantage plans, MaineHealth has advised Anthem that it intends for Maine Medical Center to continue to remain in the Anthem network for those. Also, MaineHealth has no plans to remove its physicians and other providers in its system-wide medical group from the Anthem network.

MaineHealth has also notified Anthem that the insurer will no longer be the third-party administrator of MaineHealth’s self-funded health insurance plans for its 22,000 employees beginning in 2023.

Indianapolis-based Anthem is one of the nation’s largest health insurance companies. A member of the Blue Cross Blue Shield Association, it provides coverage to people in Maine and 13 other states.