$136 for a $2 bag of saline? Anthem, MaineHealth commerce blame in billing disputes – Press Herald

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Anthem accuses the hospital community of overbilling and hiding prices; MaineHealth says the insurer is arbitrarily withholding funds.
Anthem workplaces in South Portland. Shawn Patrick Ouellette/Workers Photographer
An IV bag of saline prices Maine Medical Heart $2, however the Portland hospital has charged sufferers coated by Anthem insurance coverage a complete of $136 per bag and likewise tried to cover the invoice, in accordance with Anthem.
Anthem, alternatively, refuses to pay Maine Medical Heart for a number of procedures carried out on one affected person in the identical day, in accordance with the hospital’s guardian, MaineHealth. So when a coronary heart affected person just lately wanted two stents, Anthem would pay for just one, the hospital community alleges.
Anthem, the state’s largest insurer, and MaineHealth, the state’s greatest well being care community, offered the Press Herald with these and different examples of billing points they are saying have added as much as thousands and thousands of {dollars} in overcharges and underpayments.
The weird public accusations and particulars open a uncommon window on the well being care business’s behind-the-scenes clashes over medical prices and insurance coverage protection. Medical billing is a notoriously complicated and complicated system, with prices that may differ broadly for a similar procedures. And it’s a system that’s opaque for many customers.
The feud turned public this month when MaineHealth introduced that Maine Medical Heart, the state’s largest hospital, would go away Anthem’s insurance coverage community subsequent January, a choice that might power 1000’s of sufferers to pay far larger prices for out-of-network care. MaineHealth mentioned it introduced the transfer as a result of Anthem was shortchanging Maine Med $1 million per thirty days in remedy reimbursements whereas additionally accusing the insurance coverage firm of gradual processing and routine denials of $70 million in funds throughout the well being care community.
Anthem has confronted comparable allegations in different states. Two California hospitals threatened to go away the insurer final 12 months over the identical points however finally settled, and Georgia fined Anthem $5 million in March for the way in which it was paying claims.
If the dispute right here can’t be resolved, it may have an effect on not less than 300,000 Maine sufferers who’ve Anthem insurance coverage protection — about 54 p.c of the state’s market, in accordance with the Maine Bureau of Insurance coverage. Maine Med’s break with Anthem additionally may disrupt the state’s complete medical health insurance system by forcing large-scale shifts to different carriers. The potential impacts prompted Gov. Janet Mills to induce either side to settle the dispute.
However they look like far aside.
Anthem officers mentioned a serious cause an settlement is thus far out of attain is that MaineHealth is overcharging for affected person care. They offered the Press Herald with partially redacted medical claims to assist the accusation, together with two claims that present Maine Med charged $136 for $2 price of saline – 50 milliliters of saltwater routinely utilized in IV baggage as a car to ship medication to sufferers in hospitals. All affected person data was redacted from the claims.
Overcharging doesn’t simply drive up the insurer’s prices. It additionally means sufferers can find yourself paying larger out-of-pocket prices, in accordance with Anthem.
“Fees for saline – which they shouldn’t be charging for within the first place – and overcharges for different medicines impression customers within the type of larger price shares by deductibles and co-insurance,” Denise McDonough, president of Anthem Blue Cross and Blue Defend in Maine, mentioned in an announcement. “Companies in Maine pays extra by larger premiums or, for our self-funded prospects, larger direct prices. At Anthem, our function is to advocate for customers by defending affordability. We’re stewards of our prospects’ cash, which is why we’re standing as much as MaineHealth and asking them to proper this incorrect.”
MaineHealth officers didn’t straight reply to the accusations about saline overcharging however mentioned Anthem is cherry-picking knowledge and making an attempt to create a distraction from the central problems with the insurer failing to pay MaineHealth what it’s owed for providers.
And MaineHealth is leveling its personal accusations.
By utilizing loopholes within the contract, Anthem is at instances refusing to pay for authentic medical providers, in accordance with MaineHealth. Typically, it mentioned, Anthem will refuse to pay for 2 procedures that happen on the identical day. So when a coronary heart affected person just lately wanted surgical procedures for 2 stents, Anthem would pay for just one.
The unreimbursed prices are a part of the broader dispute over thousands and thousands of {dollars} that MaineHealth claims it’s owed by Anthem.
“These adjustments weren’t negotiated in a contract,” mentioned John Porter, MaineHealth spokesman. “They’re discovering other ways to give you new insurance policies which change our mannequin for getting paid. We will’t do enterprise like this.”
Anthem officers mentioned denying claims that seem like duplications of providers is an business customary as a safeguard in opposition to double charging by a well being care supplier. If separate medical providers are carried out, the declare will probably be paid, they mentioned.
“We have now a accountability to our members and prospects to make sure the well being care providers they obtain are coded, billed, and reimbursed appropriately and in accordance with our insurance policies aligned with business requirements,” McDonough mentioned.
Kate Ende, coverage director for the Maine nonprofit Customers for Inexpensive Well being Care, mentioned the dispute illustrates how the well being care system’s complicated approach of financing and the push-pull of negotiations between insurance coverage firms and well being care suppliers usually doesn’t finish in a approach that’s finest for customers. Within the case of the Anthem and MaineHealth dispute, it may finish with sufferers shut out of care at a serious hospital and disruption within the insurance coverage market.
“The system is overly complicated and you’ve got every get together with totally different, competing pursuits,” Ende mentioned. Well being care networks and insurance coverage firms “by quite a lot of mechanisms and levers are attempting to scale back their prices or enhance profitability.”
“The patron is usually the one left holding the bag,” Ende mentioned.
Maine Medical Heart in Portland. Gregory Rec/Workers Photographer
A key issue within the dispute is MaineHealth’s accusation that Anthem is badly lowering reimbursements for pharmaceuticals.
The hospital community says the underpayments successfully erase the advantages Maine Medical Heart must be getting from a federal low cost program generally known as 340B. Collaborating hospitals get discounted medicine in return for the care they supply to uninsured and low-income sufferers.
The 340B low cost quantities to about $1 million per thirty days in price financial savings to Maine Med. However MaineHealth says Anthem has lowered reimbursements to successfully get rid of the hospital’s financial savings. Porter mentioned Anthem is demanding MaineHealth cost Anthem just for medicine “based mostly on acquisition prices.”
Anthem spokeswoman Stephanie DuBois has mentioned the dispute of prescription drug reimbursements is just not in regards to the 340B low cost however “goes again to the truth that MaineHealth unilaterally raised prices, which is costing our members and all of Maine Medical Heart customers more cash. We will’t permit that to occur,” she mentioned.
Anthem, in the meantime, says the hospital’s saline payments are an instance of Maine Med overcharging.
Anthem officers mentioned they consider the follow is extra widespread however that the costs are hidden, similar to being listed as a pharmacy cost that might present up solely on an itemized invoice.
Throughout an audit of 96 claims, Anthem discovered $258,000 in saline prices hidden in payments, officers mentioned. They offered the Press Herald with two payments that present the $136 saline cost. Anthem officers mentioned they don’t know the scope of the issue, and will present no proof that it’s widespread, as a result of MaineHealth won’t present invoice particulars that might reveal precise prices for saline.
“We have now requested MaineHealth for knowledge so we all know the total scope of the problem, and so they have refused,” Anthem’s McDonough mentioned. “Because of this each Anthem and MaineHealth engaged an impartial mediator to assist resolve this matter. We stay dedicated to this course of in an effort to resolve this matter and hope MaineHealth will rejoin us.”
A lot of the $136 Maine Med has billed for saline is damaged out as a $125 restocking price, in accordance with Anthem. The payments offered to the Press Herald didn’t embody an in depth breakdown of the $136 cost.
“The price is a cash seize to inflate revenues, pure and easy,” McDonough mentioned. “Anthem members shouldn’t be charged for saline within the first place, not to mention should pay an exorbitant price on one thing that ought to solely price roughly $2 a bag.”
One other instance of overcharging, in accordance with Anthem, is the hospital’s inflated cost for Alloderm, which is a tissue utilized in breast reconstruction for most cancers sufferers. Anthem says the Alloderm ought to price $20,000 however that Maine Medical Heart is charging $50,000. It offered a invoice displaying a $50,000 cost.
Porter, whereas not particularly responding to the overcharging accusation, mentioned Anthem is making an attempt to divert consideration from the insurer’s “routine denials for protection of wanted care” and refusal to pay for providers. And he cited Anthem’s contract disputes with suppliers in different states.
“It’s subsequently disappointing, however not shocking on condition that it has resorted to this tactic in different states the place its practices have been at situation, that Anthem is taking hospital pricing knowledge out of context and making an attempt to distract consideration from these effectively documented points,” Porter mentioned. “We might urge Anthem to focus its consideration on the wants of sufferers, who understandably have a variety of questions on how Maine Medical Heart’s departure from its community in 2023 will have an effect on them.”
Indianapolis-based Anthem operates in 14 states and has been concerned in comparable disputes with different well being care networks, a few of which have additionally publicly criticized its practices and threatened to go away the Anthem community.
Two California hospital operators introduced final 12 months they might terminate their contracts and depart the Anthem community. The CEO of 1 hospital, Shasta Regional Medical Heart in Redding, accused Anthem of “repeated breaches of our contract,” whereas Anthem accused the hospital of making an attempt to again out of an settlement to get larger reimbursement charges. Each California hospital operators later reached new contracts with Anthem and didn’t depart the community.
Final month, Anthem was fined $5 million by the Georgia Bureau of Insurance coverage for issues that included improper claims settlement practices and gradual reimbursements.
The Maine Bureau of Insurance coverage has launched an investigation of Anthem after getting quite a few complaints from well being care suppliers about underpaying claims, a excessive proportion of denied claims and gradual reimbursements. That investigation is anticipated to take months.
Ende, of Customers for Inexpensive Well being Care, mentioned the underside line is that there’s weak regulation of the price of well being care and little safety for customers.
“There’s not a variety of oversight in how hospitals set costs,” Ende mentioned.
“There’s nothing to make sure the customers’ pursuits are actually being represented in all of this,” Ende mentioned of the dispute between MaineHealth and Anthem. “There are these totally different, competing pursuits, however no one is there totally on behalf of the buyer.”
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