Both Ende and Michaud said they see plenty of incentive for both sides to resolve disputes before January.
“There’s a lot of motivation to fix this, so I’m pretty confident that ultimately it 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 partners with MaineHealth for a very long time.”
“MaineHealth’s action of naming Maine Medical Center to our network is not how partners behave when they have differences,” McDonough said. “On the contrary, they are working together to find a compromise. We want to solve this problem for the benefit of our members and customers, and for all Maine healthcare consumers.
MaineHealth spokesman John Porter said Thursday that the network had no further comment on the dispute with Anthem.
There are still months to find an agreement that avoids major disruptions, and Ende believes it is very likely that the two sides will reach an agreement.
MOTIVATION TO COMPROMISE
Ende said Anthem could lose a lot of customers if Maine Med is no longer an in-network provider, so competitive reasons could motivate it to compromise.
“For many people, Maine Medical Center is their health care provider and the facility they use,” Ende said. “If it’s not an in-network provider, that’s definitely going to be a factor in plan selection.”
And Ende said Maine Med has a clear incentive to continue providing health care in the state’s largest population center, and it will potentially face large numbers of angry patients in its area of service if it was not networked for Anthem insurance.
“There would be a lot of disgruntled patients struggling to pay those expensive bills,” Ende said.
Although insurance plans vary, a patient undergoing a procedure at an in-network hospital may have 80-100% of the cost covered, compared to 50-60% at an out-of-network hospital. Higher copayments and out-of-pocket caps would also make care much more expensive in an out-of-network hospital. These higher disbursements 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 performed in-network as long as it can be proven that a similar procedure cannot be performed. performed nearby. . But it’s cumbersome and difficult for a patient to navigate, she says.
In addition to the dispute with MaineHealth, Michaud said many Maine hospitals are having issues with Anthem’s slow processing of claims.
Joy McKenna, spokeswoman for MaineGeneral Medical Center in Augusta, said the hospital owes Anthem $30 million and is working with the insurance company to resolve the issues.
ANTHEM PAYMENT ISSUES
A Kaiser Health News article last fall said Anthem was behind on billions of dollars in payments to hospitals nationwide due to “onerous new reimbursement rules, IT glitches and mishandled claims.” Indianapolis-based Anthem is one of the nation’s largest health insurance companies and provides coverage in 13 states in addition to Maine.
Anthem officials told Kaiser Health News at the time that they were “working to resolve” issues with timely payment of claims.
The Maine Bureau of Insurance announced this week that it is working with Anthem to resolve payment issues at a number of Maine hospitals.
Last week, the Georgia Bureau of Insurance fined Anthem $5 million for a number of consumer complaint issues, including improper handling of claims and failure to process claims promptly.
In case Anthem and MaineHealth can’t resolve the disputes, some employers are already preparing.
The State of Maine uses Anthem to administer its employee insurance plan. Kirsten Figueroa, commissioner of the Department of Administrative and Financial Services, said in an email to state employees Wednesday that while nothing will change immediately because Maine Med is on-grid for the remainder of 2022, the governor has directed DAFS “to assess what next steps might be necessary to preserve (high quality and affordable health care) for employees, should a network shutdown occur in 2023.”
Ende said despite the potential for disruption, there is plenty of time to resolve the issues between MaineHealth and Anthem.
“Nothing is changing at the moment. People who have an appointment at Maine Med next week don’t have to worry about a huge out-of-network bill,” Ende said.