MAINE, Maine — Physical therapists, optometrists, and physicians are just some of the dozens of providers who say outstanding claims are being delayed and denied by Anthem Blue Cross and Blue Shield.
In October 2021, one of the state's largest carriers told providers in a memo the delays in processing claims were due to switching to a different provider management system and hiring shortages.
But now, several months later, several Anthem providers claim they are still missing thousands of dollars in payments, and those delays are putting the care of patients in jeopardy. That includes two of Maine's largest health systems.
John Porter, the MaineHealth spokesperson, said, "MaineHealth has seen some progress from Anthem on the backlog of unpaid claims for care provided by our organization."
Porter continued, "However, we continue to see delays in processing for Anthem claims that total in the millions of dollars, as well as denials for routine care that have to be subsequently appealed or reprocessed. We continue to work with Anthem to address these issues, but so far have no definitive timeframe for resolution of the outstanding issues."
Suzanne Spruce is the chief marketing and communications officer for Northern Light Health. She said while there has been some improvement in processing the system's in-claims, "There has been no improvement with out-of-state and Medicare Advantage claims. We meet monthly with Anthem to review outstanding issues."
Caroline Fontaine is executive director of the Maine Optometric Association, representing more than 200 optometrists throughout the state. One-third said their claims are being delayed or rejected by Anthem, according to Fontaine.
"It is slow to pay or no pay. They are not in-network. The coding is wrong. They put in the wrong prefix in coding," Fontaine said.
Fontaine disputed that and said the billing codes are correct and have been used to process payments for years. She also said Anthem is demanding refunds for overpayments for services.
"They are pulling claims six to eight months back and saying they won't pay them and are taking the money back," Fontaine added.
Gwen Simons is a physical therapist and attorney. She is also the past president of the Maine Chapter of the American Physical Therapy Association.
She's heard from several physical therapists missing payments for being "out of network" despite being contracted Anthem providers. Others have had payments delayed for weeks.
"Several clinics were paid with debit cards that then got declined because there were insufficient funds that Anthem paid their services with. I don't know how that happens," Simons said.
Providers said billing issues persist despite steps taken by Anthem to rectify problems that came to a head last fall.
In a statement, Stephanie DuBois, Anthem's director of communications, said: "We have heard from many care provider partners across Maine who have thanked us for creating a dedicated team to work directly with them to resolve any issues they may have, whether they are related to the workflow challenges or standard industry practices, such as updates to clinical guidelines or benefits. We're proud of our progress, but there is more work to be done. We encourage any provider who needs assistance to call our team dedicated to meeting the needs of Maine providers. Our mission is to improve lives and communities in Maine, and we are as committed to that mission today as we were when we began nearly 85 years ago."
"Anthem is processing claims in a timely manner," DuBois said. "In the last twelve months, 92 percent of claims within 14 days, and 98 percent within 30 days. We continue to work closely with the Maine Bureau of Insurance and have met, and will continue to meet with, provider associations across Maine, including the Maine Medical Association."
Eric Cioppa, superintendent of the Maine Bureau of Insurance, said, "Since September , the Bureau of Insurance has been meeting weekly with Anthem so it can monitor the situation with provider reimbursement. Anthem has made progress to get these issues resolved; however, it is still working through some backlogs. Anthem reports that it has taken several steps to resolve these issues, including deploying resources from other areas of the company, developing better communication methods to providers, pausing reimbursements edits, and establishing a dedicated provider line. Provider inquiries to the bureau have dropped off considerably since last fall. We encourage providers having reimbursement issues to use Anthem's new dedicated provider line."
The Maine Anthem provider line is 1-833-690-2936 and is available Monday -Friday from 8:30 a.m.-5 p.m. EST. To stay up-to-date on information or changes that may affect claims processing in the future, providers can sign up to receive important updates by email.
The Bureau of Insurance is performing a "market conduct exam" to figure out why providers are not getting paid. The exam could result in Anthem being forced to pay the providers what they are owed, plus interest: 1.5% per month or 18% per year. That exam is expected to be completed in several months.
Dr. Jeffrey Barkin is the president of the Maine Medical Association. It represents about 3,000 providers across Maine. He recently met with Anthem officials after hearing from members who said claims are being processed faster but still delayed.
Barkin said Anthem officials are willing to continue to meet quarterly, potentially as a payor-provider committee, to resolve ongoing billing issues.
"So that should problems occur down coding, denial of claims, and other sorts of behavior that threaten the health of Mainers, we hope the committee will identify and prevent that," Barkin said.