Maine Powerless In Big Fight Between Its Largest Insurer And Hospital

MaineHealth's April announcement that it would pull its flagship hospital, Maine Medical Center in Portland, out of a contract with Anthem Blue Cross Blue Shield at the end of the year due to financial friction. Such a move would carry seismic implications for Maine's health care landscape.

Maine Medical Center is unique because of its size and services it offers. Anthem is Maine's largest insurer and the decoupling would mean anyone covered by it would be billed for costlier out-of-network services if they sought care at Maine Medical Center, except emergency care.

The argument between two private entities puts the state in a semi-helpless position. While the Maine Bureau of Insurance conducts a lengthy but regularly scheduled review of Anthem's practices, politicians are using their bully pulpits to push both sides to seek agreement. Republicans on the Legislature's health insurance committee highlight Anthem's argument and cost concerns while Democrats urge a more general outlook.

"If not addressed, this split will result in healthcare cost increases that far exceed general inflation, making healthcare and health insurance increasingly unaffordable for Maine's citizens," said a Wednesday news release from Republicans on the Legislature's health insurance panel.

Driving the schism is $70 million in what MaineHealth has characterized as unpaid claims, along with changes to the hospital's contract with Anthem that affect reimbursements. There is a wider problem. A December survey from the Maine Hospital Associated showing roughly $350 million in debt to members and independent providers have complained about Anthem as well.

Anthem has admitted operational issues that have affected claims, but the company alleges that MaineHealth used those problems to its advantage in the media and said the real issue between the parties is that the provider is "materially overcharging" for services.

Those arguments have played out in the press and also before the health insurance committee while both parties are still in remediation. Anthem has also begun a small digital ad campaign urging Mainers to sign a petition and stand up to "MaineHealth's egregious overbilling."

The Republican released pinned the issue on MaineHealth's reach in the state, saying its domination of the market has empowered the system to overcharge for services. It also suggested a free-market approach to health care — the idea that less regulation will lead to less costly services and better competition providers — would work to solve the problem.

The letter was not meant to side with Anthem but to pressure both sides to work out a deal, said Rep. Josh Morris, R-Turner, who sits on the committee and said he was disappointed how the dispute has played out in the media.

"If Anthem needs to pay some money, they need to pay it," he said. "The concern is that MaineHealth certainly has the ability to terminate its contract, but that's not in the best interest for consumers."

There is little the state can do. Maine Bureau of Insurance Acting Superintendent Timothy Schott has said his office is conducting a market review of Anthem and has been in touch with both parties on resolving their issues. Anthem could face penalties if it is found to have operated improperly. But the state does not get involved in contractual disputes.

Maine has taken steps to nip some contractual issues in the bud, passing an amended version of a law Morris sponsored last year that strengthened reporting requirements for provider agreements. It was supported by the Maine Hospital Association, opposed by the Maine Association of Health Plans — who r epresent the state's biggest insurers — and received neutrally by the state.

Democrats have been more wary to park blame at any party's feet. Gov. Janet Mills has pressed for reconciliation, saying ending the contract "should be avoided at all costs." Maine AllCare, a group that advocates for universal health care, called it "a stunning example of why market forces can't do the job."

Both entities may have issues to solve, said Rep. Denise Tepler, D-Topsham, a member of the insurance committee. But she noted problems with Anthem have been reported by others in Maine and across the country.

"That's something we want everyone to be aware of," she said.

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