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

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

Contract disputes with Anthem and hospital networks in recent years have played out in Indiana, Georgia, California, Virginia, Colorado, New York, Nevada, Ohio and Connecticut, although most disputes don’t result in hospitals leaving 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, 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 fairly common. And when private negotiations go awry, the sides sometimes air grievances in public, much as Anthem and MaineHealth have in recent weeks. But it is rare for a  major hospital to actually pull out of an insurer network and potentially cause thousands of patients to pay out-of-network fees for receiving their hospital care. And when breakups happen, they typically don’t last long.

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

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

Some health care industry observers in Maine are predicting a similar dynamic will occur between MaineHealth and Anthem, with a settlement to avoid 300,000 Anthem customers being out-of-network starting in January. That would avoid patients potentially being saddled with large out-of-network bills and employers having to switch insurance plans, among other disruptions.

But in the meantime, the two sides in Maine appear to be far apart. And in Maine, the disagreement pits the state’s largest health care provider in MaineHealth against the largest insurer in Anthem. At 300,000 members statewide, Anthem represents 54 percent of the insurance market in Maine.

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

MaineHealth – the parent organization of Maine Med in Portland, seven other Maine hospitals and one in New Hampshire – is accusing Anthem of shortchanging its health care providers by denying payments for services rendered. Anthem says MaineHealth routinely overcharges for medications. Both sides have provided examples, such as Maine Med charging $136 for a $2 bag of saline solution and Anthem only agreeing to pay for one of two heart stent procedures performed on the same patient in the same day.

Mitchell Stein, a Maine-based health policy consultant, said that while the fact that the MaineHealth-Anthem dispute became so rancorous and public is unusual, these types of disputes happen periodically.

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

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

“There’s a constant strive for balance, and when insurers are feeling out of balance, these contract disputes can happen,” said Stein, a volunteer board member for Lewiston-based Community Health Options, an insurance cooperative.

Stein said the way the United States funds its health care system is so convoluted that hospital prices, what insurers will pay and what patients may end up owing is often skewed in reality-bending ways, resulting in charges like $50 for a Tylenol. The hospitals and insurance companies have competing interests, which may or may not align with patients’ interests.

“Don’t blame the players, blame the game,” Stein said. “But the hospitals do do some things to bring this on themselves.”

Both MaineHealth and Anthem have been leveling accusations at each other during the current standoff.

John Porter, MaineHealth spokesman, said a similar dispute in Indianapolis resulted in a federal arbitrator ruling that Anthem had to pay back $4.5 million in claims.

“Anthem continues to deny claims and prior authorizations for coverage at an excessive rate, creating stress for MaineHealth’s patients and their caregivers. Across Maine it has failed to pay claims to hospitals and independent providers totaling more than $100 million. Similar to its behavior in Indiana, it continues to create new policies unilaterally so as to reduce payments to providers below contractually agreed upon rates,” Porter said in a statement.

The Indiana dispute did not result in hospitals leaving the Anthem network, but was based on claims stretching back to 2017. The Georgia Bureau of Insurance also recently fined Anthem $5 million for slow processing of payments and denied claims. The Maine Bureau of Insurance is currently conducting a monthslong “market examination of Anthem, which will include a review of provider payment issues.”

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

“Anthem Blue Cross and Blue Shield in Maine is 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 also centers on ensuring care is affordable. Across the industry it is not uncommon to have this divergence of viewpoints; 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 have not seen in Maine is a health system announcing its intention to drop a hospital from a care provider network in the middle of a contract,” DuBois said in a statement.

But Sean Barry, a spokesman with 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 in unpaid or delayed payments represents substantial portions of the hospital or health system’s revenue, putting considerable financial strain on their ability to deliver care,” Barry said in a statement. “This is particularly challenging now in an environment of soaring input costs and growth in general inflation.”

Some independent health care providers – which lack the negotiating leverage of a large health care network like MaineHealth – are also having issues with Anthem.

Fore River Urology of South Portland on Monday announced that it was leaving the Anthem network, starting on Aug. 1 for commercial insurance and Sept. 1 for Medicare Advantage plans, because Anthem was reimbursing at rates far below what the service costs, according to Fore River Urology.

Related Stories