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Maine lawmakers examine dispute between MaineHealth and Anthem

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.

On Thursday, lawmakers on the legislature's Health Coverage, Insurance and Financial Services Committee took up the dispute between MaineHealth and Anthem. MaineHealth recently announced Maine Medical Center would no longer be an in-network provider for Anthem as of 2023. The consequences of such a move for consumers have raised alarms. Committee members are trying to decide what actions to take in their role of providing oversight of both the state employees' health plan and the Maine's Bureau of Insurance, which is conducting a review of Anthem.

The committee first heard from MaineHealth CEO Andrew Mueller, who reiterated the points he made earlier this month. Mueller said Anthem owes MaineHealth $70 million in back payments and is withholding an additional $13 million a year from Maine Medical Center over disputed payments. It comes at a time, he said, when the health system has already taken a financial hit from the COVID pandemic.

"We feel like we're down and wounded, and we're getting kicked pretty hard at the worst possible time," Mueller said.

Mueller also accused Anthem of making midyear changes to coverage, including prohibiting providers from billing for more than one procedure per day per patient. He gave the example of a cancer patient who had a hysterectomy and a lymph node biopsy the same day, but coverage of the biopsy was denied. When the president of Anthem in Maine, Denise McDunough, spoke to the committee, she said that the insurance company is scrutinizing claims to ensure providers are billing appropriately. And in 2018, she said, Anthem discovered overcharges which resulted in MaineHealth refunding $20 million to patients.

"The real issue between Anthem and MaineHealth is the result of Anthem having discovered that MaineHealth is materially over-charging Anthem and its members," McDunough said.

The two sides provided a "he said/she said" view of the situation, and comments from Maine's Bureau of Insurance shed little light. The Bureau is conducting a market review of Anthem, but Acting Superintendent Tim Schott said findings are confidential until the review is complete — which will likely take several months. But he said Maine law does have protections for consumers.

"There is a right for continuity of care," Schott said, which requires insurance coverage for consumers to continue for at least 60 days after a contract is terminated. But that's of little consolation to groups insured by Anthem, including 68,000 active and retired teachers and their families and more than 25,000 state employees. If Maine Medical Center is not a part of Anthem's network, patients who receive non-emergency care at the hospital would likely be billed at higher rates.

Anya Trundy of Maine's Department of Administrative and Financial Services said state employees' current health plan with Anthem runs through next June, and there isn't enough time to switch insurers before then.

"This termination should be avoided at all costs," Trundy said.

While lawmakers and regulators are urging MaineHealth and Anthem to reach a resolution, testimony during a public comment period was mostly directed at Anthem. A spokesperson from the American Hospital Association said issues with the insurer aren't unique to Maine. And Jeff Austin of the Maine Hospital Association said they're not unique to MaineHealth. As of the end of last year, he said, Anthem owed hospitals in the state $350 million.

"It's become easier to do the brain surgery than to collect payment for brain surgery," Austin said.

Independent providers also expressed frustrations with Anthem. Jay Mullen is CEO of Blue Water Health, a physician-owned medical group that staffs emergency rooms. He said currently 25% of its Anthem payments are past due, and the insurer uses policies that harm patients who have legitimate concerns that send them to emergency rooms.

"When, after the thorough ED evaluation, including x-rays, EKG's, lab work, etcetera, it turns out they have a non-emergent conditions," Mullen said. "Anthem is denying coverage or reducing payment for that ED visit."

Others took a broader view of the situation and urged lawmakers to look beyond just resolving the current dispute between MaineHealth and Anthem. Karen Foster of the group Maine AllCare suggested it's time to seriously consider universal health care, which she said would be simpler and better for consumers.

"I haven't heard anyone say why don't we take a look at the forest instead of focusing on the trees?" Foster said.

It's unclear what the outcome of the legislative meeting will be. After several hours of testimony, committee chair Democratic Senator Heather Sanborn said there was a lot of information to digest and there are no specific next steps.