PORTLAND, Maine — The parent company of Maine's largest hospital announced Wednesday that beginning in 2023, Anthem health insurance would no longer be an in-network provider at Maine Medical Center.
According to MaineHealth, Anthem owes them more than $70 million for health care services dating back more than three years. MaineHealth also said Anthem is withholding another $13 million related to disputes over how much MaineHealth should charge for services.
The change would affect all Anthem subscribers, including those who are covered through their employer and those who buy insurance directly from Anthem, as well as those covered through the Affordable Care Act's exchange.
Anthem does not own all Blue Cross Blue Shield affiliations, so just because someone has BCBS, does not mean they will be out-of-network. You can find those lists here.
DISPUTE OVER MONEY
Mueller said MaineHealth and Anthem tried to come to a resolution but has been unable to do so, and thus informed Anthem that the hospital plans to terminate its contract with the insurance provider beginning Jan. 1, 2023.
"It's a total of about $13 million per year that they're withholding from Maine Medical Center, and those are dollars that come straight from our bottom line that we could otherwise use to invest in our care team, our communities, and services that are needed," Andy Mueller, MaineHealth CEO, said Wednesday during a news conference.
Anthem spokesperson Stephanie DuBois said in a statement:
"MaineHealth has been overcharging our members and all Maine Medical Center consumers and this is unacceptable. Those overcharges stem from variety of services.
What's more, we pay MaineHealth a set amount on a regular basis in advance of services being rendered. This process has been in place for many years to ensure they have a regular cash flow, which we feel is important to ensure access to care.
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."
In another statement, Dubois said:
“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.”
A second issue relates to $70 million in unpaid billed claims. According to MaineHealth, Anthem has not made payments to many health care providers in Maine and has blamed system errors. The insurer has also denied prior authorizations and referrals.
In October 2021, Anthem told providers that it was experiencing delays in the switch from one provider management system to another and that a hiring shortage was exacerbating the problem.
The Maine Bureau of Insurance said it had been meeting weekly with Anthem to "monitor the situation with provider reimbursement" but that the company was still working through the backlog.
EFFECT ON PATIENTS
The termination applies only to Maine Medical Center, according to Mueller. It does not affect primary care physicians or specialists at other MaineHealth locations or doctors at MaineHealth hospitals.
"We don't want to disrupt anyone's care. By any stretch of the imagination. So we thought long and hard about all of our patients before making this decision," said Mueller.
Anthem subscribers could still get health care at MMC but at out-of-network coverage rates. Under federal law, Anthem must continue to fully cover emergency care at MMC even without an in-network agreement.
The change does not affect people on Medicare Advantage plans: they will still be considered "in-network" at Maine Medical Center.
Anthem is Maine's largest insurer: more than 300,000 people in the state have it for medical insurance, including tens of thousands of people who work for the state of Maine.
Mueller said they are alerting patients now to give them, and health care workers, time to prepare. MaineHealth sent a letter to roughly 157,000 patients in the system who have Anthem and have gotten care at MMC in the last three years.
His concern is that if this lack of payment continues, it will start to affect the care and service MaineHealth can provide.
"We're at a point we feel, as a health care system, we've got to defend ourselves," said Mueller. "This is an existential issue for us so, yeah, it's drastic because if we don't somehow get through this, this puts our ability to deliver needed services to our communities in jeopardy."
Mueller said MaineHealth might have to cut back services, and that the first to go would be the least used ones. Mueller said rural parts of the state would be most affected, but he does not want that to happen.
MaineHealth is also ditching Anthem as the healthcare provider for its nearly 22,000 employees.
"We can't have a healthcare player for our own care team in which our own care team is out-of-network in one of our facilities," said Mueller.
Mueller said discussions including mediation with Anthem for months have been unsuccessful. Dubois said Anthem is committed to resolving the issue.
"Anthem and MaineHealth are not currently in active contract negotiations. Anthem and MaineHealth have a contract that runs through September 30, 2024. This current agreement also continues the aforementioned program that Anthem provides upfront payments to MaineHealth," DuBois told NEWS CENTER Maine. "The biggest outstanding dispute stems from a routine audit that again uncovered overcharging by MaineHealth, and whether members covered by other plans were also impacted. Anthem and MaineHealth have engaged an independent mediator to help resolve this matter, and we remain committed to this process in an effort to resolve this matter."
Maine Gov. Janet Mills issued a statement Wednesday expressing strong concerns about the announcement.
"I am deeply concerned about the potential for a contract termination between MaineHealth and Anthem," Mills said.
"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. Termination should be avoided at all costs," Mills continued.
"The Governor believes that State employees and their families deserve high-quality, affordable health care and it is her Administration’s plan to continue delivering it. She has directed the Department of Administrative and Financial Services to evaluate what next steps may be needed to preserve that commitment to employees, should this network removal occur in 2023," wrote Kelsey Goldsmith, communications director for Maine's Department of Administrative and Financial Services.
Gov. Mills' sister, Dora Mills, is the chief health improvement officer for MaineHealth.
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