Maine Medical Center plans to leave the Anthem insurance network in January 2023 because of the insurer’s payment practices, including what hospital officials say is $13 million in underpayments to the hospital and more than $70 million in unpaid claims to the MaineHealth network.
The dispute pitting the state’s largest hospital against Maine’s largest health insurer could affect more than 150,000 patients, forcing them to pay higher out-of-pocket costs at Maine Med.
Maine Medical Center in Portland is the flagship hospital of the MaineHealth network, which announced the change Wednesday. MaineHealth has seven other hospitals in Maine and one in New Hampshire that will continue to be part of the Anthem network.
An Anthem spokeswoman blamed Maine Medical Center for charging unacceptable fees and indicated that there’s a chance the dispute could be resolved.
“There is a long way to go before the end of the year, and we would think they will work with us on resolving these issues,” Anthem spokeswoman Stephanie DuBois said in a written statement.
Gov. Janet Mills issued a statement saying she is “deeply concerned” and urged the two sides to resolve their differences.
“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.”
OUT-OF-POCKET COSTS WILL INCREASE
The move would mean Maine Medical Center becomes an out-of-network health care provider for people who are insured by Anthem, either through their jobs, the Affordable Care Act marketplace or as individuals. The change would increase out-of-pocket costs for Anthem patients who receive non-emergency care at the hospital. It would apply to non-emergency care only because Anthem would be required by law to fully cover emergency care, MaineHealth said.
While insurance plans vary widely, out-of-network care generally costs patients far more than in-network. For instance, the price of an in-network procedure might be 80 to 90 percent covered by insurance or even fully covered, while insurance may only pay 50 to 60 percent of an out-of-network procedure. Other patient costs such as co-pays and out-of-pocket maximums also are higher when getting out-of-network care. In one analysis of a $22,000 hospital bill by the California Department of Managed Care Health, an in-network cost to the patient was $2,800, while the same care provided out-of-network would cost the patient $13,600.
Mitchell Stein, a Maine-based independent health policy analyst, said that insurers and health care networks have payment disputes all the time.
“What is unusual is that these disputes don’t usually end up being aired in public,” said Stein, a volunteer board member for Community Health Options, the Lewiston-based health insurance cooperative.
He said insurers and health care systems have different motives for their bottom line. The insurers are attempting to limit the costs that they pay to hospitals to keep premiums down for their members, while hospitals are trying to maintain revenue streams to pay for the services they provide.
“There aren’t good guys and bad guys in this. There are competing interests,” Stein said.
MaineHealth estimates the decision would affect more than 150,000 Anthem patients based on the number of patients who made a claim at Maine Med during the past three years.
“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,” said Dr. Andrew Mueller, CEO of MaineHealth. “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.”
Anthem owes MaineHealth more than $70 million for health care services dating back over three years, MaineHealth said. Anthem also has been reducing negotiated payments to the Portland hospital that should not be in dispute, Mueller said.
DuBois, the Anthem spokeswoman, said that “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.
“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 ALLEGES OVERBILLING
DuBois said MaineHealth has been “overcharging our members” for at least four years and “this is unacceptable.”
“During a routine review in 2018, Anthem discovered overbilling by Maine Medical Center for anesthesia and operating room services. We worked with MaineHealth to identify the Anthem members impacted by this, and as a result of our investigation, MaineHealth eventually relented and issued refunds to our members for the amount they were overcharged. These overcharges amounted to nearly $20 million to our members. If it were not for our audits, these overcharges may never have been discovered.”
John Porter, MaineHealth spokesman, said the health care network would have no comment in response to Anthem’s statement about increased charges.
While MaineHealth said its entire network is owed money by Anthem, the issue is most critical at Maine Medical Center.
Mueller, in a news conference on Wednesday, said Anthem is withholding $1 million per month in payments to Maine Med. He said the reduction is about equivalent to payments the hospital receives from the 340B federal medication discount program, which lowers the cost of prescription drugs to hospitals that have a high number of Medicaid patients.
Mueller said Anthem has not admitted that program is the cause of the reduction, but he believes it is not a coincidence. He said if MaineHealth doesn’t stand its ground on the issue, it could set a precedent and result in reductions by Anthem across all nine of the system’s hospitals. The dispute is an “existential” threat to MaineHealth services, Mueller said.
DuBois said the dispute is not about 340B but “goes back to the fact that MaineHealth unilaterally raised charges, which is costing our members and all of Maine Medical Center consumers more money. We can’t allow that to happen. We’ve been trying to resolve this and now they appear to be walking away.”
NEGOTIATIONS ‘DIFFICULT’ FOR LONG TIME
Mueller said negotiations with Anthem have been “difficult” for a long time, and reached an impasse in January.
“We seemed to be moving farther and farther apart,” Mueller said.
Mueller said the drastic move comes as a last resort, because if the reduced payments continue, financial pressures could lead to services being threatened, especially in rural areas. “We have a lot of other issues we would rather tackle,” Mueller said.
Timothy Schott, acting superintendent of the Maine Bureau of Insurance, encouraged the two sides to reach an agreement.
“The Bureau of Insurance has been in contact with both MaineHealth and Anthem about the concerns in their relationship,” Schott said in a statement. “While the bureau cannot get involved in contractual matters, it has encouraged both parties to work in good faith to resolve their differences well before January 1. The Bureau is currently considering how best to work with Anthem to ensure that it maintains an adequate network of providers so its members can get the benefits to which they are entitled.”
The move will not affect subscribers to Anthem-MaineHealth Medicare Advantage plans. MaineHealth said the Portland hospital will remain in-network for those patients. Also, MaineHealth said it has no plans to remove its physicians and other providers in its systemwide medical group from the Anthem network, and no other hospitals are affected.
MaineHealth also is dropping Anthem as the insurance carrier for its 22,000 employees, starting in January 2023. A new carrier has not yet been chosen, Mueller said.
COMPLAINTS ABOUT TIMELY PAYMENTS
The decision comes on the heels of months of complaints by hospitals about Anthem’s issues with paying health care providers in a timely manner.
“We’ve been getting a lot of complaints from hospitals. Providers are saying their claims aren’t getting processed,” said Steven Michaud, president of the Maine Hospital Association. “There’s been a big problem.”
Northern Light Health, which operates Northern Light Mercy Hospital in Portland, continues to experience “some delays” with Anthem payments but is working with the insurer and meeting monthly to discuss outstanding issues, Senior Vice President Suzanne Spruce said in a written statement.
Judith Watters, spokeswoman for the Maine Bureau of Insurance, said in an email response to questions that the “Bureau of Insurance is aware of the payment issues providers have experienced with Anthem.”
“The bureau is conducting a market conduct examination of Anthem, which will include a review of provider payment issues. The exam is expected to continue for several months. At this time, Anthem has worked through most of its backlog of claims,” Watters said.
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. Its share (ANTM) price rose $12.09, or 2.44 percent, on Wednesday, to close at $506.87.