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Anthem Health fined for violations in Maine
June 5, 2025
Audit reveals claims and appeals violations and inadequate record keeping.
Tag(s): Advocacy, Third Party
Key Takeaways
- Anthem Health Plans of Maine has agreed to pay a $100,000 civil penalty and correct violations.
- The Maine Optometric Association, as part of the Maine Alliance of Health Care Professionals, filed a complaint against Anthem for issues including a long credentialing process for new providers, failing to use standard coding rules when processing claims, and failing to pay interest on late claims payments.
- The AOA offers resources for members to help hold insurers accountable.
Anthem Health Plans of Maine has agreed to pay a $100,000 civil penalty and correct violations detailed by the state’s insurance regulators in a recent market conduct examination report on the health insurer’s practices.
This comes after the Maine Optometric Association, as part of the Maine Alliance of Health Care Professionals, filed a complaint against Anthem for issues including a long credentialing process for new providers, failing to use standard coding rules when processing claims, and failing to pay interest on late claims payments.
“The completion of the Anthem audit is a significant victory for optometry and all health care professionals in Maine,” says Jessilin Quint, O.D., president of the Maine Optometric Association. “This report validates our concerns and underscores the power of unity in driving change. It’s clear that optometry is not alone in facing challenges from insurance companies, and together, we are stronger in ensuring fair treatment and improved patient care.”
The examination by the Maine Bureau of Insurance, which is required by state law every five years, covered Anthem's activities from October 2019 to September 2021. Anthem offers vision coverage among its plans, but vision care was not specifically discussed in the report’s findings.
The report cited claims-processing violations, appeals-process violations, and inadequate record keeping. Specific violations included:
- 2,240 autism, mental and behavioral health, or substance use disorder claims had incorrect cost-sharing applied.
- 80 appeals were missing required coordinator contact information, and 36 appeals had untimely acknowledgment letters.
- 31 claims were denied beyond the required 30-day timeframe.
- 25 pharmacy claims had inadequate documentation.
In addition to the fine, Anthem is required to conduct quarterly self-audits beginning in July to prove it has corrected the issues outlined in the report. According to the state’s insurance superintendent, Anthem had already corrected several issues.
Resources for holding vision plans accountable
Interested in learning more about payer advocacy efforts or aware of discrimination or other harmful actions by policies or insurers? Help the AOA hold insurers accountable by taking the following steps:
- Report plan abuses to the AOA at stopplanabuses@aoa.org.
- Visit the AOA’s Action Center to learn more about federal legislation that could curb common and egregious plan abuses.
- Consider investing in AOA-PAC, the only federal political action committee dedicated to fighting and winning for optometry.
Have questions? Contact the AOA’s Third Party Center by email.