Anthem Blue Cross Blue Shield, the state’s dominant health insurance carrier, is a publicly-traded, for-profit company based in Indianapolis, Indiana that reported a first quarter profit of $1.8 billion, equal to over $7 billion a year in profit alone. In 2021, providers became aware that Anthem was unilaterally “down-coding” claims of health care providers. This resulted in the providers being paid substantially less – on the order of 75% – than what they would have been paid had their charges been honored. In addition, for a time Anthem was unable to pay any claims due to a claims processing technical overhaul that was seriously flawed upon its implementation.
While this may appear simply as a technical business dispute, Maine health care providers were not paid for patient services they legitimately provided. This impacted providers of all types. Imagine the solo practitioner who had to turn to a home equity line-of-credit in order to keep a practice alive. Imagine the largest hospital in the state – Maine Medical Center – having to separate from Anthem because of nonpayment. Imagine countless other health care providers – ranging from physical therapists, optometrists, and behavioral health practitioners to physicians of all types and to hospitals – being unpaid by Anthem. The bottom line is that all of this puts care to our patients in jeopardy and that should be the only priority in fixing this problem.
Anthem’s behavior has caused many health care providers to leave the company’s network and this has led to patients having their insurance refused by these providers. While providers continue to be willing, ready, and able to care for our patients, the insurer’s failure to pay claims simply shifts the financial burden to the patients. No health care provider can offer critical services to the community without being paid.
The current crisis with Anthem’s treatment of health care providers of all types creates an opportunity that should not be missed. Specifically, we encourage:
• The Legislature empowers the Bureau of Insurance to more strongly address the health care needs of the people of Maine. The Bureau of Insurance has a primary role to ensure the financial stability of the health insurers, including Anthem. It is important that the legislature find creative ways to compel the Bureau of Insurance to represent the interests of Maine patients when they are caught in disputes between insurance carriers and health care providers.
• In medicine, we practice according to evidence-based best practices. This is an opportunity to ensure that health insurers follow best practices as well. It is also an opportunity to identify worst practices that must be avoided. We strongly encourage the legislature to delineate specific and explicit practices which would more robustly hold insurance companies to predefined and agreed upon goals such as paying claims on time, avoiding unilateral down coding, or other obstructive processes that are dangerous to providers and patients alike. Simply put, the current crisis with Anthem provides an opportunity to do better.
The current discussion has been too focused on insurance company utilitzation management techniques. Patients are mentioned only in the context of dollar and cents within a business plan. Referring to patients as numbers instead of people ignores their suffering. Patients are sick people with anxiety, fear, and differing personal circumstances, not a series of numbers on a keyboard plugged into a computer alogrithym without a name. The doctors and nurses of Maine spend every day, face-to-face with real people, talking. laughing, crying, and hoping. They trust each other.
The people of the Maine Medical Association and Maine Hospital Association know first hand what difficult discussions take place every day at the kitchen table and exam table, and are best suited to help facilitate the negotiating table process to identify best practices. It is our hope that by explicitly defining and codifying them we can prevent a recurrence of the present crisis of confidence with Anthem.
— Special to the Press Herald
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