Mainebiz

H ealthcare costs are a real con- cern for families and busi- nesses in Maine. Premiums and out-of-pocket costs continue to rise. Employers are trying to keep their costs in check and lawmakers are looking for long-term solutions. However, while there is no single fix, there are practical steps we can take. At Anthem Blue Cross and Blue Shield in Maine, we believe focusing on costs starts with getting the ba- sics right. That means paying claims quickly and accurately, reducing un- necessary paperwork, and making sure care is guided by clear medical standards. Paying Claims Quickly A claims system that works well helps everyone. Anthem processes more than half a billion medical claims annually. More than 95 percent are approved within 15 days. For providers, this means reliable and timely reimbursement, allow- ing practices and hospitals to focus on patient care rather than billing follow-up. Prompt payment supports strong provider networks and reduces friction that can strain relationships across the system. For employers, timely claims pro- cessing translates to fewer billing disruptions for employees and few- er escalations to HR departments. For legislators focused on system performance, it demonstrates that administrative efficiency at scale can reduce waste and improve the overall healthcare experience in Maine. Reducing Preventable Denials Claims denials can be frustrating. It is important, however, to ground the conversation in data. Denials are uncommon and are typically prevent- able. The most common causes here in Maine, in order, are: 1. Duplicate claims filed for the same service; 2. Eligibility issues (e.g., claims submitted to us for non-Anthem members); and 3. Billing/coding errors in the claim submission. We recognize that even prevent- able denials create burden. That is why Anthem continues to invest in electronic claims tools, clearer ben- efit information, and improved data sharing to reduce avoidable errors. By streamlining submission processes and improving transparency around coverage requirements, we aim to minimize administrative friction and ensure providers are paid promptly for the care they deliver. For employers and policymakers, reducing avoidable denials is not just about convenience, it is about eliminating unnecessary adminis- trative costs that ultimately drive premiums higher. Using Prior Authorization Responsibly and Sparingly Prior authorization is often debated. The reality is that we use it in a lim- ited and targeted way. Only approx- imately 3 percent of non-emergency care requires prior authorization. (Emergency care is never subject to prior authorization.) The vast majority of care proceeds without additional review, and most prior authorization requests are ultimately approved. We are committed to ensuring our members receive safe, high-quali- ty, evidence-based care. Prior autho- rization helps confirm that services meet established clinical guidelines while supporting appropriate, cost-ef- fective treatment. At the same time, we recognize the need to continuously improve. Since January 2024, Anthem has removed prior authorization requirements for more than 400 services. We are com- mitted to ongoing evaluation of where requirements can be streamlined or eliminated without compromising quality or safety. For providers, this means a con- tinued focus on simplification. For employers, it means responsible oversight that helps manage long- term cost trends. For legislators, it demonstrates that utilization man- agement can evolve in response to stakeholder feedback. A Shared Responsibility for Maine's Future No one group can solve rising health- care costs alone. Providers are facing higher operating costs. Employers also face rising costs, and healthcare is typically their second highest expense, after payroll. Lawmakers must balance complex priorities. Health plans must ensure that pre- mium dollars are spent wisely, as healthcare costs drive premiums. The path forward requires ac- countability from all involved. Paying claims promptly, reducing avoidable administrative barriers, applying clinical review thoughtfully and sparingly, and continuously modernizing systems to reduce complexity are daily focus areas for us at Anthem. We remain committed to collabo- rating with providers, employer-cus- tomers, and policymakers in Maine to build a system that delivers value — one that supports high-quality care while also containing costs for the people and businesses who depend on it. S P O N S O R E D C O N T E N T Paying Claims on Time and Cutting Red Tape: What Maine Patients and Providers Deserve Want to learn more? Visit anthem.com/affordabilityinmaine By Denise McDonough, President, Anthem Blue Cross and Blue Shield in Maine

• Cover