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Independent health care providers in Maine express frustration with Anthem's payment practices

FILE - In this May 14, 2019, file photo signage on the outside of the corporate headquarters building of health insurance company Anthem is shown in Indianapolis. Anthem Inc. reports financial earns on Wednesday, Oct. 23.
Michael Conroy
FILE - In this May 14, 2019, file photo signage on the outside of the corporate headquarters building of health insurance company Anthem is shown in Indianapolis. Anthem Inc. reports financial earns on Wednesday, Oct. 23.

As a licensed clinical professional counselor, it's Tiffany Manson's job to help other people manage stress and anxiety. But lately, the Lewiston-based counselor says she's had to deal with a fair amount of it herself.

"I have never experienced this much stress and this much anxiety in my field as a clinician until these issues with Anthem," Manson says.

Manson says she hasn't been paid by Anthem since November. She says the insurance company incorrectly processes her claims as out-of-network, which costs more for her clients. And when she contacts Anthem to fix the issue, inevitably another problem with her paperwork delays payment.

"So they kept saying, 'Oh, we're not paying you because your address is wrong.' And it's like, so I'm in network, but it's my address. Then my address gets fixed, and I'm out of network. Then I get in network, and I'm still not getting paid because they're processing it out of network," Manson says.

She says a third of her clients are insured by Anthem, and she can't afford the delayed payments or the time it's taking to try to resolve the issue.

"I had to take a week off in February, I took a whole week off and spent a whole week dealing with this," she says. "Talking to Anthem, trying to appeal things and nothing has been fixed. "

On Wednesday, MaineHealth announced that it will pull Maine Medical Center out of Anthem's network next year due to payment issues. But the problems that are creating a fracture in the relationship between MaineHealth and Anthem are being experienced elsewhere in the health care system. The issue is so widespread among mental health providers, the National Association of Social Workers in Maine hosted a virtual listening session with Anthem in mid-March.

"And what we heard over and over again is that clinicians in the state of all levels are going unpaid,' says Chris McLaughlin, the executive director of the Association. "Their message and attempts to figure out what's going on are going unanswered. They're getting denial notices without any indication as to why."

McLaughlin says the situation has gotten so bad, some therapists have dropped out of Anthem's network. That means clients have to pay out of pocket, which erects a barrier to accessing mental health services at a time when they're in high demand, says Amy Safford, the executive director of the Maine Psychological Association.

"And I think everyone recognizes now how important mental health care is to overall health care, right?" says Safford. "And at the same time, you have insurance companies not paying the providers that are the foundation of the system."

The battles to get paid by Anthem spread to other independent providers, from physical therapists to eye doctors, including optometrist Dr. William Gove in Falmouth.

"It's been a nightmare," Gove says. "It's been a very difficult year."

He says Anthem has continually denied claims he submits, saying the information is incorrect.

"Which it was not," he says. " And this was upwards of 50 to 60 patients that I got letters for that I was denied payment for over three to four months. And some of those patients they still haven't paid for."

Anthem's actions have upset his patients and make him look like the bad guy for supposedly not filling out paperwork correctly ,he says. It's created so much of a headache that Gove is considering dropping out of Anthem's network.

Dr. Jeffrey Barkin, president of the Maine Medical Association, says other providers have already left, due to what he describes as a clear and consistent pattern by the insurance company that started last summer.

"Anthem began to do a process called pre-adjudication edits, where they would take the bill of doctors and just unilaterally downcode them," says Barkin. " It's like putting in your 40 hour a week pay period and getting 11 hours only."

In a letter sent to Maine providers, Anthem has blamed billing problems on the company's upgrade last August to a new data management system. Spokesperson Stephanie DuBois says the company, which is headquartered in Indianapolis, has created a dedicated team to assist Maine providers and is proud of the progress it's made. But she says the issues are complex and it will take time to address them properly.

Meanwhile, Anthem is being monitored by the Maine Bureau of Insurance, which is also performing a market conduct examination of the company.