Editorial: Medical billing murky at best   

Last spring, Maine Medical Center decided to play hardball with Anthem Blue Cross and Blue Shield. MaineHealth officials announced that the state’s largest hospital would leave the state’s largest health insurance network in 2023. 

Officials at the Portland hospital alleged Anthem owed millions in unpaid or underpaid claims. Anthem alleged that the hospital was overbilling. Unresolved, the dispute could have brought higher out-of-pocket costs on more than 150,000 patients.  

That crisis was averted last week when MaineHealth and Anthem announced they had reached a deal to keep the hospital in-network for the coming year. Governor Janet Mills said she wanted to review the details of the agreement, adding, “but I welcome that it will preserve access to health care for Anthem customers at Maine Medical Center. There is no question that termination of the contract would have significantly harmed many people, especially those with chronic care needs.” 

As with so many things to do with medical billing, the details of the contract are opaque to the general public. Maine has made inroads on increasing pricing transparency, but for most of us the greatest medical mystery is just how much the bill will be after an ER visit or outpatient procedure. 

One place to start is CompareMaine.org, where data from the Maine Health Data Organization’s All-Payer Claims Database is compiled and broken down by insurance provider. Prospective patients can compare average costs for common procedures across hospitals. But the data, based on median payments, are incomplete and meant only to help in comparison shopping. Your actual bill may be very different. CompareMaine also does not include information on the uninsured or patients on Medicare and MaineCare. 

New federal rules that took effect this summer require insurers and self-insured employers to publicly post the prices they pay for health care services. But the list price may be different from what insurers have negotiated with individual providers. Moreover, the digital files as presented on many insurers’ websites are not user-friendly.  

For those experiencing emergencies, especially in rural areas, there’s no shopping around. Even patients who do seek out estimates in advance are often surprised by the final bill. 

And while the state’s largest hospital and insurer have leverage in pricing negotiations, individual patients rarely do. 

Receiving only partial compensation or none at all for care of certain patients, hospitals shift costs around to stay afloat. Insurers are passing more costs onto their clients. 

“Facility fees” often inflate bills far above what patients were expecting, according to recent reporting by the Portland Press Herald, and insurers frequently deny claims with little clarity on the decision making. After rounds of frustrated phone calls, patients “often give up and pay, worn down by a system that is as time-consuming as it is obtuse.” 

The last thing anyone needs when they are ill or recovering is an enormous debt hanging over their head. 

Meanwhile, so much of the emphasis in American health care is on treating issues when they’ve reached a critical level. Much lip service is paid to preventative care and general wellness, but costs keep many Americans out of the doctor’s office until they can postpone no longer. 

Change is slow going and hard fought. The recently passed Inflation Reduction Act, for instance, caps annual prescription costs for Medicare beneficiaries and allows the federal government to negotiate prescription drug prices for seniors, reforms that have been long debated. 

Real change for all Americans seems very far away. Most are left navigating a convoluted system where they bear enormous financial responsibility with little say. 

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