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Health

Maine Medical Center will drop Anthem as in-network insurer

George HW Bush Falls
David Sharp
/
AP file
This July 16, 2015, photo shows the Maine Medical Center in Portland, Maine.

There's a major shakeup in the state's health insurance market. On Wednesday, MaineHealth announced that Maine Medical Center will drop out of Anthem's network of providers next year. Officials say they were forced to make the decision because Anthem owes the system $70 million in outstanding payments.

MaineHealth CEO Andrew Mueller says the outstanding payments date back three years. And the health system has tried to resolve the issue with Anthem, to no avail.

"To be sure, it's been difficult for a really long time and I think for us, recognize that we weren't making any progress in mediation and were moving farther and farther apart," Mueller says.

On top of the $70 million in unpaid claims, he says, Anthem has reduced payments at Maine Medical Center by about a million dollars a month since August. Mueller says the situation is financially unsustainable, and that's why he decided to pull MaineHealth's largest hospital, Maine Medical Center, out of Anthem's network starting in 2023.

"Yeah, it's drastic. Because if we don't somehow get through this, this puts our ability to put our needed services to our community in jeopardy," Mueller says.

The decision doesn't affect MaineHealth's Medicare Advantage Anthem subscribers or emergency care. But any non-emergency care that Anthem patients receive at Maine Medical Center will be billed as out of network, which usually costs more — sometimes full price. Mueller says he tried to minimize disruption by only pulling out Maine Med. Other MaineHealth hospitals will still be in Anthem's network.

"For example, Southern Maine Medical Center, Mid Coast medical center in Brunswick," Mueller says.

Anthem is the largest insurer in the state, covering more than 320,000 people, including state employees, the Maine teachers' union, and — until the end of this year — even MaineHealth employees. The executive director of Consumers for Affordable Health Care, Ann Woloson, says no matter how you slice it, this decision is disruptive to patients.

"If Maine Medical Center remains out of network, people with Anthem coverage after January 1st, 2023, will likely pay more for the care they receive at that hospital," Woloson says.

Even if Anthem patients choose a different MaineHealth hospital, Woloson says it's not a guarantee that their provider will be in-network and that they'll be billed at a lower cost.

"So say you want to have a baby and you're seeing an obstetrician in a southern part of the state," Woloson says. "Having a baby in another part of the state may seem like a logical step to avoid those out of network costs, but you also have to make sure that the provider you're working with, the surgeon you're working with, are also going to an in-network provider at the hospital you choose."

Gov. Janet Mills says the severed relationship between Maine Medical Center and Anthem would cause significant harm to patients. In a written statement, Mills urged the two parties to "put the interests of Maine people first" and reach an agreement that avoids a drastic move.

But the president of the Maine Hospital Association, Steven Michaud says he's not surprised the situation has gotten to this point — and it extends to other Maine hospitals. The association surveyed members in December after hearing widespread frustrations about Anthem. Michaud says 30 hospitals reported issues with delayed payments and denials of claims.

"Very significant amounts of money, $350 million was owed and some of it, tens of millions over a year old, owed the hospitals, so it just really culminates into clearly there's a big problem," Michaud says.

It also extends to hospitals in other states. The American Hospital Association wrote a letter to Anthem in September in response to complaints, urging the company to fix payment problems. And just last week, the state of Georgia fined Anthem $5 million for violating policyholder's rights.

For its part, Anthem says it conducted audits on MaineHealth and found $20 million in overcharges to its members. Spokesperson Stephanie DuBois says Anthem is "committed to resolving these years-long issues with MaineHealth." She says under its contract, Anthem also pays MaineHealth a set amount in advance of services that are delivered. DuBois admonished the system for alarming 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, ” she says.

Asked if MaineHealth would reconsider its decision, CEO Andrew Mueller says it's possible.

"We need less of a transaction and more of a partnership," Mueller says. "I think if we can get to that point with them, and we can see how both of can move forward to achieving our goals, then there's hope for the relationship."