PORTLAND — MaineHealth has served notice that its flagship hospital, Maine Medical Center, will no longer participate as an in-network provider of non-emergency care for Anthem’s commercial subscribers starting in 2023.
The change would impact 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 Dr. Andrew Mueller, CEO of MaineHealth. “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.”

The decision to pull MMC out of the Anthem network is 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.

As has been reported in the news in recent months, 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.

According to the statement from MaineHealth, 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. “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 MMC from the Anthem network because the insurer has been focused on MMC. 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, N.H.

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. Patients often have to pay more out-of-pocket to use a provider out of an insurer’s network. Under the law, Anthem must continue to fully cover emergency care at MMC even without an in-network agreement. And MaineHealth is committed to do what it can to reduce the impact that this change will have to patients covered by Anthem.

MaineHealth has advised Anthem that it intends for MMC to continue to remain in the Anthem network for subscribers to Anthem|MaineHealth Medicare Advantage plans. 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. 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.