Maine Med’s exit from Anthem’s network would disrupt Maine’s insurance market, experts say

Both Ende and Michaud said they see a lot of incentive for both sides to resolve conflicts before January.

“There’s a lot of motivation to get this resolved, so I’m confident that at the end of the day this won’t happen,” Michaud said.

Denise McDonough, president of Anthem Blue Cross and Blue Shield in Maine, said in a statement Thursday that “we have been a partner with MaineHealth for a long time.”

“MaineHealth’s decision to exclude Maine Medical Center from our network is not how partners behave when they have differences,” McDonough said. “Rather, they work together to find a compromise. We want to resolve this for the benefit of our members and customers, and for all health care consumers in Maine.”

John Porter, a spokesman for MaineHealth, said Thursday that the network had no further comment on the dispute with Anthem.

There are still months to go to reach a deal that would avoid a major disruption, and Ende believes the two sides are very likely to reach an agreement.

MOTIVATION TO COMMITMENT

Ende said Anthem could lose many clients if Maine Med is no longer an in-network provider, so competitive reasons could motivate it to commit.

“For many people, Maine Medical Center is their health care provider and the facility they use,” Ende said. “If they are not an in-network provider, that will certainly be a factor in plan selection.”

And Ende said Maine Med has a clear incentive to continue providing care in the state’s largest population center, and would potentially face a large number of angry patients in its service area if it weren’t in-network. Anthem.

“There would be a lot of dissatisfied patients struggling to pay these expensive bills,” Ende said.

Although insurance plans vary, a patient who has a procedure at an in-network hospital may have 80 to 100 percent of the cost covered, compared to 50 to 60 percent at an out-of-network hospital. net. Higher copays and out-of-pocket maximums would also make care much more expensive at an out-of-network hospital. Those higher out-of-pocket expenses could add up to thousands of dollars depending on the cost of the procedure.

Ende said there is a process to have a procedure performed at an out-of-network hospital and have it covered by insurance as if it were performed in-network, as long as it can be shown that a similar procedure cannot be performed nearby. . But it’s cumbersome and difficult for a patient to navigate, he said.

In addition to the dispute with MaineHealth, Michaud said many Maine hospitals are having trouble with Anthem’s slow processing of claims.

Joy McKenna, a spokeswoman for MaineGeneral Medical Center in Augusta, said Anthem owes the hospital $30 million and is working with the insurance company to resolve the issues.

ANTHEM PAYMENT PROBLEMS

A Kaiser Health News story last fall said Anthem was billions of dollars behind in payments to hospitals across the country due to “onerous new reimbursement rules, computer problems and mishandled claims.” Headquartered in Indianapolis, Anthem is one of the nation’s largest health insurance companies, providing coverage in 13 states plus Maine.

Anthem officials told Kaiser Health News at the time that they were “working to rectify” problems with timely payment of claims.

The Maine Insurance Bureau reported this week that it was working with Anthem to resolve payment issues at several Maine hospitals.

The Georgia Bureau of Insurance last week fined Anthem $5 million for a series of consumer complaint issues, including improper claims processing and failure to timely process claims.

In case Anthem and MaineHealth can’t work out differences, some employers are already preparing.

The State of Maine uses Anthem to administer its employee insurance plan. Kirsten Figueroa, commissioner of the Department of Financial and Management Services, said in an email to state employees Wednesday that while nothing will change immediately because Maine Med is on the network for the remainder of 2022, the governor has directed DAFS to “ evaluate the next steps. may be necessary to preserve (high-quality, affordable health care) for employees, in the event of a network removal in 2023.”

Ende said that despite the potential for disruption, there is plenty of time to work out the issues between MaineHealth and Anthem.

“Nothing is changing right now. People who have an appointment at Maine Med next week don’t have to worry about getting a huge out-of-network bill,” Ende said.

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