Maine Medical Center plans to leave the Anthem insurance network in January because of the insurer’s payment practices, including $13 million in underpayments to the hospital and more than $70 million in unpaid claims to the MaineHealth hospital network.
The dispute pitting the state’s largest hospital against one of Maine’s largest health insurers could affect more than 150,000 patients, who would have to pay higher out-of-pocket costs at Maine Med.
Maine Medical Center in Portland is the flagship hospital of the MaineHealth network, which is the state’s largest hospital system and announced the change Wednesday. A spokeswoman for Anthem said the company was preparing a response to the announcement.
The move will mean Maine Medical Center will be 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. The change would apply to non-emergency care only because Anthem would be required by law to fully cover emergency care, MaineHealth said.
MaineHealth estimates more than 150,000 Anthem patients 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, according to MaineHealth. Anthem has also been reducing negotiated payments to the Portland hospital that should not be in dispute, it said.
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, a program that lowers the cost of prescription drugs to hospitals that have a high share 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 of the system’s nine hospitals. The dispute is an “existential” threat to MaineHealth services, Mueller said.
He said negotiations with Anthem have been “difficult” for a long time, but 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, services, especially in rural areas, could be threatened,
“We have a lot of other issues we would rather tackle,” Mueller said.
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 system-wide medical group from the Anthem network, and no other hospitals are affected.
MaineHealth is also 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.
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.”
Judith Watters, of 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.
This story will be updated.
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