BANGOR (AP) – A stalemate over fees means the only provider of open-heart surgeries in northern Maine will be leaving the network of the state’s largest health insurer.

Anthem Blue Cross and Blue Shield of Maine announced last week that it rejected a demand for what it described as an “extraordinary increase” in fees for Cardiovascular Surgery, P.A., a Bangor-based practice that includes four doctors.

The decision means that effective Sept. 1 most Anthem patients will have to face either higher out-of-pocket expenses or travel to heart surgery centers in Lewiston or Portland.

Dr. Robert Clough, who has practiced in Bangor for 18 years, said the 40 percent fee increase was designed to bring Anthem’s payment schedule in line with other private insurers. After a brief back-and-forth, he said, Anthem stopped negotiating.

“So we’re opting out of participation,” he said. An estimated 10 to 12 percent of the practice’s patients are affected by the break with Anthem. People enrolled in Anthem’s Medigap plan, however, are not affected by the change.

Clough said expenses have gone up because of increases in malpractice insurance, the aging population of northern Maine, and other factors.

“No doctor comes to Bangor to get rich,” he said. “But I’m trying to run a small business here.” The practice performs 600 or 700 open-heart procedures each year, using the surgical facilities of Eastern Maine Medical Center.

The breakdown between Anthem and Cardiovascular Surgery could set a precedent for private insurers who choose to give patients incentives to travel to less expensive practices rather than giving in to physicians’ demands for higher fees, said Deputy Commissioner Judy Shaw from the Maine Bureau of Insurance in Augusta.

Frank John, executive director of employee health and benefits for the state of Maine, said he was disappointed that a compromise was not reached, allowing Cardiovascular Surgery to remain in Anthem’s network of preferred providers.

John said he was still hopeful that that the parties could return to the table and reach a compromise after a cooling-off period.

If the decision stands, Anthem policyholders will likely pay more if they choose Cardiovascular Surgery for their care because physicians usually charge more when a patient is covered by an insurance company with which the doctor doesn’t have a contract, said Anthem spokesman Mark Ishkanian.

Though the percentage of the bill that a patient is responsible for paying may stay the same – typically 20 or 40 percent – it is calculated on a higher amount. And, he added, most plans also require patients to pay a higher per-visit co-payment for out-of-network care.

Ishkanian said Anthem plan members who opt to travel to Portland or Lewiston for heart surgeries will receive a travel stipend of up to $150 per trip.

Information from: Bangor Daily News, http://www.bangornews.com

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