Anthem agrees to pay $100,000 civil penalty following complaint filed in part by Maine Optometric Association

The Maine Bureau of Insurance’s examination is required by state law every 5 years, and thus covered Anthem’s activities from October 2019 to September 2021. Image credit: AdobeStock/rustyelliott

Following a complaint filed by the Maine Optometric Association with the Maine Alliance of Health Care Professionals, Anthem Health Plans of Maine has agreed to pay a $100,000 civil penalty and rectify violations in a recent market conduct examination report.¹ Those violations had been detailed by Maine’s insurance regulators via the Maine Bureau of Insurance, according to an American Optometric Association (AOA) news release.

The complaint from the association detailed issues such as 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 release stated.

“The completion of the Anthem audit is a significant victory for optometry and all health care professionals in Maine,” said Jessilin Quint, OD, president of the Maine Optometric Association, in the release. “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 Maine Bureau of Insurance’s examination is required by state law every 5 years, and thus covered Anthem’s activities from October 2019 to September 2021. Although Anthem offers vision coverage among its plans, vision care was not specifically discussed in the report’s findings. Violations cited in the report include claims processing, appeals process, and inadequate record keeping, with 31 claims denied beyond the required 30-day timeframe, 25 pharmacy claims found with inadequate documentation, 80 appeals missing required coordinator contact information, and 36 appeals cited with untimely acknowledgement letters.¹

Anthem will also be required to conduct quarterly self-audits beginning in July of this year to document the correction of the issues stated in the report.¹ The company has already corrected several issues, according to the state’s insurance superintendent, as stated in the release.

“Several of the issues identified in the report have been corrected, and we appreciate Anthem’s attention to these matters,” Maine Insurance Superintendent Bob Carey told Agency Checklists.² “The Bureau will continue to monitor Anthem’s corrective action in this matter to ensure Anthem’s compliance with all applicable laws and regulations.”

References:

1. Anthem Health fined for violations in Maine. News release. American Optometric Association. June 5, 2025. Accessed June 12, 2025. https://www.aoa.org/news/advocacy/third-party/anthem-health-fined-for-violations-in-maine

2. AC Editor. Anthem Market Conduct Examination report results in $100k penalty. Agency Checklists. May 30, 2025. Accessed June 12, 2025. https://agencychecklists.com/2025/05/30/anthem-market-conduct-examination-report-results-in-100k-penalty-75949/