In California, a hospital left the Anthem insurance network over a dispute over reimbursements before reaching an agreement and joining less than a month later.

In Connecticut, a hospital group left the Anthem network over a contract disagreement in 2017, then rejoined after a deal was reached several weeks later.

In recent years, contract disputes with Anthem and hospital networks have arisen in Indiana, Georgia, California, Virginia, Colorado, New York, Nevada, Ohio and Connecticut, although most disputes do not lead to the departure of hospitals from the insurance networks.

Now MaineHealth and Anthem are locked in a tense contract dispute, with the hospital network saying Maine Medical Center in Portland will leave the Anthem network starting in January 2023. About 150,000 Maine Med patients have used Anthem insurance in recent years. years, so the move would potentially leave many patients with Anthem insurance paying high out-of-network fees or finding other medical providers.

Disputes between hospitals and insurers are quite common. And when private negotiations go awry, parties sometimes air grievances in public, much like Anthem and MaineHealth have done in recent weeks. But it’s rare for a major hospital to pull out of an insurer network and potentially force thousands of patients to pay out-of-network fees to receive their hospital care. And when breakups do happen, they usually don’t last long.

In one example, Dignity Health in California removed Sierra Nevada Memorial Hospital from the Anthem network in July 2021. Anthem and Dignity Health traded accusations in the media, but ultimately settled a month later and covered all hospital care. hospital retroactively so that no patient was off-grid.

When the similar dispute in Connecticut was resolved in 2017, coverage was also retroactive, so no Anthem patients ended up out of the network.

Some healthcare industry watchers in Maine are predicting a similar dynamic will play out between MaineHealth and Anthem, with a settlement to keep 300,000 Anthem customers out of the network starting in January. This would save patients from potentially being saddled with large out-of-network bills and employers from having to switch insurance plans, among other disruptions.

But in the meantime, the two parts of Maine seem to be far apart. And in Maine, the rift pits the state’s largest healthcare provider MaineHealth against Anthem’s largest insurer. To 300,000 members statewide, Anthem represents 54% of the insurance market in Maine.

Indianapolis-based Anthem is one of the nation’s largest health insurance companies and provides coverage to residents of Maine and 13 other states.

MaineHealth — the parent organization of Maine Med in Portland, seven other Maine hospitals and one in New Hampshire — accuses Anthem of harming its healthcare providers by withholding payments for services rendered. Anthem says MaineHealth routinely overcharges medications. Both parties provided examples, such as Maine Med charging $136 for a $2 saline bag and Anthem only agreeing to pay for one of two cardiac stent procedures performed on the same patient on the same day. .

Mitchell Stein, a Maine-based health policy consultant, said while it’s unusual for the MaineHealth-Anthem dispute to become so spiteful and public, these types of disputes do occur periodically.

“It happens with large, for-profit national insurance companies; they go through periods of being more aggressive in their negotiations with health care providers,” Stein said. “It happened with United a few years ago, and also with Cigna. If there is a cycle of higher claims, that puts pressure on premiums, and they try to keep premiums low.

Stein said another dynamic is that Medicare recently announced a lower-than-expected service reimbursement rate increase, which is also causing some hospitals to raise prices from private insurers.

“There is a constant search for balance, and when insurers feel out of balance, these contractual disputes can arise,” said Stein, volunteer board member of Community Health Options, a Lewiston-based insurance cooperative. .

Stein said the way the United States funds its healthcare system is so convoluted that hospital prices, what insurers will pay and what patients might end up owing are often skewed in ways that circumvent reality, leading to fees like $50 for a Tylenol. Hospitals and insurance companies have competing interests, which may or may not align with the interests of patients.

“Don’t blame the players, blame the game,” Stein said. “But hospitals are doing certain things to blame themselves.”

MaineHealth and Anthem have blamed each other during the current standoff.

MaineHealth spokesman John Porter said a similar dispute in Indianapolis resulted in a federal arbitrator’s decision that Anthem should repay $4.5 million in claims.

“Anthem continues to deny claims and pre-approvals for coverage at an excessive rate, creating stress for MaineHealth patients and their caregivers. Across Maine, it failed to pay claims against hospitals and independent providers totaling more than $100 million. Similar to his behavior in Indiana, he continues to unilaterally create new policies to reduce vendor payments below contractually agreed rates,” Porter said in a statement.

The dispute in Indiana did not result in hospitals leaving the Anthem network, but was based on claims dating back to 2017. The Georgia Bureau of Insurance also recently fined Anthem $5 million for slowness. payment processing and denial of claims. The Maine Bureau of Insurance is currently conducting a “month-long market review of Anthem, which will include a review of vendor payment issues.”

Stephanie DuBois, spokeswoman for Anthem, said they were “committed to addressing this issue and hope MaineHealth will join us.”

“Anthem Blue Cross and Blue Shield in Maine are committed to providing access to quality, outcomes-driven healthcare, and we believe MaineHealth shares these goals. Where our two perspectives diverge is that our work at Anthem is also about ensuring care is affordable. Across the industry, it is not uncommon to have this divergence of views; in fact, it is part of the normal course of business for insurers and health systems to engage in negotiations regarding cost and quality. What we haven’t seen in Maine is a health system announcing its intention to remove a hospital from a provider network in the middle of a contract,” DuBois said in a statement.

But Sean Barry, a spokesperson for the American Hospital Association, said the group “continues to hear reports of significant issues with Anthem, including delays in paying claims and policies that restrict or delay access to care”.

“For some hospitals and health systems, the amount of unpaid or delayed payments represents a substantial portion of hospital or health system revenue, placing significant financial pressure on their ability to provide care,” said Barry in a statement. “This is particularly difficult now in an environment of soaring input costs and rising general inflation.”

Some independent healthcare providers — who don’t have the bargaining power of a large healthcare network like MaineHealth — are also having issues with Anthem.

Fore River Urology of South Portland announced Monday that it is leaving the Anthem network, beginning Aug. 1 for commercial insurance and Sept. 1 for Medicare Advantage plans, as Anthem reimburses at rates well below the cost of service, according to Fore Fluvial Urology.

“This unfortunate outcome further erodes the suitability of Anthem’s provider network in southern Maine,” said Ben Hinchey of Schooner Healthcare Resources, who represents Fore River Urology. Notices were sent to about 10,000 Anthem patients on Monday. Anthem officials countered by saying Fore River wanted to increase reimbursement rates by 50% and declined more “reasonable” increases.

” Previous

Following ”