Maine Medical Center’s plan to leave Anthem’s health care provider network in January would cause a broad disruption in the state’s health insurance market, affecting individuals and businesses alike, experts say.

Large employers, including the state of Maine, could be prompted to switch insurance companies, moving thousands of people to other carriers such as Aetna, Harvard Pilgrim or Community Health Options.

For individuals who stay with Anthem – about 300,000 people in Maine currently have an Anthem plan – and need to go to Maine Medical Center for care, paying out-of-network fees would increase costs dramatically. About 150,000 people with an Anthem plan made a claim at Maine Med during the past three years, according to hospital officials.

Kate Ende, policy director for Consumers for Affordable Health Care, a Maine-based nonprofit that helps people access health insurance, said ripple effects of the separation would reverberate throughout the industry.

“There would definitely be disruption, and a lot of access issues with Maine Med being the largest tertiary care provider in Maine,” Ende said.

MaineHealth, the parent organization of Maine Med, made the stunning announcement Wednesday that it would remove the Portland hospital from Anthem’s network in January 2023 because the insurer was not paying millions of dollars in claims for the hospital’s services.

The two health industry giants are at loggerheads over payment issues, with Anthem claiming MaineHealth is overcharging for services. MaineHealth officials say Anthem is improperly withholding $13 million in payments for medications and owes MaineHealth $70 million for services rendered that are tied up in processing delays.

FEELING THE PAIN

Steven Michaud, president of the Maine Hospital Association, said that the impacts of the breakup would be enormous.

“It would be very significant for individuals and businesses,” Michaud said. “This is the biggest tertiary care hospital in Maine and the largest insurance carrier. You almost can’t comprehend how disruptive it would be.”

The dispute has such a great potential to upend health markets that Gov. Janet Mills issued a statement on Wednesday strongly urging the two sides to rectify the problems. “Termination of the contract would significantly harm the cost of and access to care for Maine people who are Anthem customers, particularly in southern Maine, and seriously impact the operation of the health care market across the state,” Mills said.

Both Ende and Michaud said they see a lot of incentives for both sides to resolve the conflicts before January.

“There’s a lot of motivation to resolve this, so I am quite confident that at the end of the day this 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 terming Maine Medical Center from our network is not how partners behave when they have differences,” McDonough said. “Rather, they work together to find compromise. We want to resolve this for the benefit of our members and customers, and for all healthcare consumers in Maine.”

John Porter, MaineHealth spokesman, said Thursday that the network had no further comment about the dispute with Anthem.

There are still months to work out a deal that avoids major disruption, and Ende believes it’s very likely the two sides could reach an agreement.

MOTIVATION TO COMPROMISE

Ende said Anthem could lose a lot of customers if Maine Med is no longer an in-network care provider, so competitive reasons could motivate it to compromise.

“For a lot of people, Maine Medical Center is their health care provider and the facility they use,” Ende said. “If they’re not an in-network provider, it’s certainly going to be a factor in plan selection.”

And Ende said Maine Med has a clear incentive to continue to provide health care in the state’s largest population center, and it would potentially face a large number of angry patients in its service area if it was not in-network for Anthem insurance.

“There would be a lot of unhappy patients struggling to pay these expensive bills,” Ende said.

While insurance plans vary, a patient who has a procedure at an in-network hospital might have 80 to 100 percent of the cost covered, compared to 50 or 60 percent at an out-of-network hospital. Higher co-pays and out-of-pocket maximums also would make care far more expensive at an out-of-network hospital. Those higher out-of-pocket expenses could add up to thousands of dollars depending on the cost of the procedure.

Ende said there is a process for having a procedure done at an out-of-network hospital and getting it covered by insurance as if it were performed in-network as long as it can be proven that a similar procedure can’t be done nearby. But it’s cumbersome and difficult to navigate for a patient, she said.

In addition to the dispute with MaineHealth, Michaud said many Maine hospitals are having issues with slow claims processing by Anthem.

Joy McKenna, spokeswoman for MaineGeneral Medical Center in Augusta, said the hospital is owed $30 million by Anthem and is working with the insurance carrier to resolve the issues.

ANTHEM’S PAYMENT PROBLEMS

A Kaiser Health News story last fall said that Anthem was behind on billions of dollars in payments to hospitals nationwide because of “onerous new reimbursement rules, computer problems 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 rectify” issues with timely payment of claims.

The Maine Bureau of Insurance reported this week that it was working with Anthem to resolve payment issues at a number of Maine hospitals.

The Georgia Bureau of Insurance last week fined Anthem $5 million over a number of consumer complaint issues, including improper processing of claims and failure to promptly process claims.

In the event that Anthem and MaineHealth can’t resolve differences, 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 in network for the rest of 2022, the governor has directed DAFS to “evaluate what next steps may be needed to preserve (high-quality, affordable health care) to employees, should a network removal occur in 2023.”

Ende said that despite the potential for disruption, there’s a lot of time to resolve the issues between MaineHealth and Anthem.

“Nothing is changing right now. People who have an appointment at Maine Med next week, they don’t have to worry about getting a huge out-of-network bill,” Ende said.