PORTLAND – On April 6, MaineHealth announced to the state that its Portland hospital, Maine Medical Center, was pulling out of the Anthem Blue Cross and Blue Shield in Maine health insurance network next year.  Gov. Janet Mills weighed in later in the day with a statement urging the two entities to work it out. Anthem responded April 7 that it wanted to, “restore affordability at Maine Medical Center.”

“The health system recognizes the decision could be disruptive for people with Anthem coverage, but the issues at stake threaten MaineHealth’s ability to provide the same level of care,” said MaineHealth, April 6, in a news release.

MaineHealth said it served Anthem notice that Maine Medical Center would no longer participate as an in-network provider of non-emergency care for Anthem’s commercial subscribers starting in 2023.

The change would affect those who get Anthem coverage from their employer, as well as those who buy insurance directly from Anthem, including through the Affordable Care Act’s exchange.

“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 Andrew Mueller, MD, CEO of MaineHealth, in the release. “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.”

MaineHealth said it was disengaging with Anthem: “based on how the insurer’s practices in recent years have impacted MMC and its patients. Anthem owes MaineHealth in excess of $70 million for health care services dating back over three years. Anthem has also been reducing negotiated payments to MMC that should not be in dispute.”

In countering MaineHealth, Anthem cited increases in health services charges at Maine Med.

“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,” said Stephanie DuBois, director of public relations for Anthem Blue Cross and Blue Shield in Maine. “This has resulted in direct higher costs to our members and all consumers that use Maine Medical Center, which is unacceptable.”

She added: “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.”

She said that MaineHealth has been overcharging Anthem members and all Maine Medical Center consumers for, “at least four years.”

“During a routine review in 2018, Anthem discovered overbilling by Maine Medical Center for anesthesia and operating room services,” said Anthem.

“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,” said DuBois. “These overcharges amounted to nearly $20 million to our members. If it were not for our audits, these overcharges may never have been discovered.”

She said that Anthem paid 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,” said Anthem.

MaineHealth cited news coverage, saying that Anthem: “has been struggling with making payments on time to many health care providers across Maine, including MMC, blaming system errors for the problem. Anthem also has been denying prior authorizations and referrals for needed care, forcing patients and their physicians to appeal or resubmit claims. Last summer, Anthem denied proper reimbursement to in-network providers because it was using incorrect provider identification numbers. As a result, Anthem incorrectly denied claims for 10,000 MaineHealth accounts.”

MaineHealth continued in its release: “While the insurer has said publicly that it is fixing its systems and putting its problems behind it, that has not been the experience of MaineHealth. Last week, the Georgia Office of Insurance and Fire Safety fined Anthem $5 million for practices similar to what MaineHealth has experienced.”

“We would not pull Maine Medical Center out of Anthem’s network unless we felt we absolutely had to,” said Mueller, in the release. “We have been in discussions, including mediation, with Anthem for several months and have made little progress. While we want to work productively with all our partners, we have to prioritize our ability to deliver the high level care our communities depend on us to provide. This is especially true when we are navigating through a global pandemic and its aftermath, which has placed tremendous strain on our caregivers and our resources.”

MaineHealth said it only plans to remove Maine Medical Center from the Anthem network because the insurer has been focused on Maine Medical Center.

“MaineHealth also hopes that confining the change to MMC will minimize the impact on patients covered by Anthem and any disruption in its service area of 11 counties in Maine and Carroll County, New Hampshire,” it said.

MaineHealth said that leaving the Anthem network would not necessarily prevent patients covered by Anthem from using MMC, but insurers typically do not cover care obtained from out-of-network providers at the same level as those that are in-network.

For subscribers to Anthem|MaineHealth Medicare Advantage plans, MaineHealth said it advised Anthem that it intends for MMC to continue to remain in the Anthem network for those. Also, MaineHealth has no plans to remove its physicians and other providers in its system-wide medical group from the Anthem network, nor, as noted above, any hospital other than MMC.

Under the law, Anthem must continue to fully cover emergency care at MMC even without an in-network agreement, said MaineHeatlh.

“And MaineHealth is committed to do what it can to reduce the impact that this change will have to patients covered by Anthem,” said MaineHealth.

MaineHealth has also notified Anthem that the insurer will no longer be the third-party administrator of MaineHealth’s self-funded health insurance plans for its employees beginning in 2023.

Anthem said that Anthem and MaineHealth are not currently in active contract negotiations.

“Anthem and MaineHealth have a contract that runs through September 30, 2024,” said Dubois. “This current agreement also continues the aforementioned program that Anthem provides upfront payments to MaineHealth. 

“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.”

Gov. Janet Mills said April 6: “I am deeply concerned about the potential for a contract termination between MaineHealth and Anthem. Maine Medical Center is the largest tertiary care hospital in Maine and Anthem is the state’s largest insurer, serving more than 300,000 people, including State employees.

“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. As both private parties negotiate the contract, I strongly urge them to put the interests of Maine people first, to resolve this issue in a timely way, and to reach an agreement that averts the need for such a drastic, damaging move.”