HANOVER — Katherine Bramhall has been a midwife for almost 20 years and delivered thousands of babies, but now, insurance issues are threatening the future of her practice.
“This is all I do. I don’t go on vacation. I don’t even go home,” Bramhall, who splits time between her home in Barre, Vt. and an apartment in Lebanon, said at Gentle Landing Birth Center off Buck Road last Friday. She delivers about 80 babies every year at the practice she opened in 2021. The clinic has nine employees, though not all are full time.
As of Friday morning, Bramhall, 66, said there was just $300 in the business’ bank account and around $60,000 in unpaid reimbursements from Anthem Blue Cross Blue Shield dating back as far as April 2024.
With bills stacking up and more expenses looming, Bramhall hit a breaking point when she started receiving bills to pay $9,000 in overpaid reimbursements back to Anthem.
On Feb. 2, she took to social media and GoFundMe.
“For 15 months, Gentle Landing Birth Center has been fighting a silent battle,” the GoFundMe reads. “While our midwives have been welcoming babies, supporting families through postpartum, and launching new food security programs, we have been simultaneously fighting for our financial life against a broken insurance system.”
Bramhall’s goal is to raise $35,000 to cover supplies, utilities and payroll to continue operating the clinic and pay $13,000 in overdue rent.
As of Friday, Bramhall had raised $21,000 which she said offers some relief, including covering rent and a business loan payment.
Bramhall is committed to staying open to maintain the option for families in the Upper Valley, she said Friday, but the path forward looks difficult.
“Losing this birth center impacts the future of hope for families in the Upper Valley,” Bramhall said Friday. “I won’t do it.”
The billing issues, she said, stem from ongoing technological and communication problems with the insurance company that accounts for 80% of Gentle Landing’s insurance receivables.
Despite no changes to the way the practice does billing, Bramhall said Gentle Landing started seeing “endless denials” of what she said should have been valid insurance claims in October 2024. Around the same time, Anthem instructed the practice to switch to a digital billing platform called Availity and no longer assigned the clinic a representative, which Bramhall said made resolving issues nearly impossible.
Availity is a digital administrative platform that insurers use to communicate with providers, including processing billing and tracking benefits information.
Despite the clinic having had a contract with Anthem since 2021, the insurer was flagging its claims as out of network. Gentle Landing staff would update information such as the clinic address and contact information at the direction of the insurance provider.
“We just kept on doing what we were told … they kept on re-denying things, and we kept on fixing what they would say,” Bramhall said.
The tipping point came last week, when Anthem notified Bramhall that she had to return thousands of dollars in over-payments for past reimbursements.
“It is a profound irony that Anthem lacks the capacity to pay a small provider for the work she has actually done, yet possesses the ruthless efficiency to audit and demand money back within a strict window,” she wrote in a statement to Anthem and news organizations last week.
A spokesperson for Anthem denied any fault for the ongoing reimbursement issues.
“Our Anthem team has spent an extensive amount of time reviewing the issues with both the practice and the billing agency hired by the practice,” Jim Turner, a spokesperson for Anthem New Hampshire, said Tuesday. “We have explained to the billing company how to submit the claims appropriately — to ensure timely payment. Despite those efforts, the billing company has not yet corrected the errors. We will continue to work with the billing company and Gentle Landing Birth Center to resolve the matter, but we need their cooperation to do so.”
In 2025, Anthem processed 6.6 million claims with more than 95% in two weeks and 99% within 30 days, Turner said.
Gentle Landing Birth Center works with Texas-based billing company Competitive Edge Billing and Contracting. Records show that communication is ongoing between Anthem, Gentle Landing Birth Center and the billing company.
Last February, Bramhall filed a complaint with the New Hampshire Insurance Department that resulted in two claims being readjusted, according to documentation from Anthem and the Insurance Department. The clinic’s records show about 30 claims still outstanding, according to emails from Competitive Edge.
The New Hampshire Insurance Department declined to comment on this investigation citing RSA 400-A:16, which exempts insurance complaints from New Hampshire’s right-to-know law. The Department also did not comment on Anthem’s past sanctions.
In November, the New Hampshire Insurance Department fined Anthem $520,000 for a series of issues in 2022 and 2023, including not maintaining accurate documentation and provider information, not credentialing providers in a timely manner and not appropriately overseeing third-party platforms, according to an order from the insurance department.
In 2023, the New Hampshire Hospital Association also released a report outlining “universal dissatisfaction” with Anthem and almost $300 million in outstanding payments from Anthem to New Hampshire hospitals.
Since last week, Bramhall said she has had several New Hampshire providers contact her to share similar experiences.
Steven Peña has been a chiropractor in Walpole, N.H., for 40 years and has dealt with Blue Cross Blue Shield since the beginning, he said Tuesday. In August, two years after moving his clinic a few streets over from its previous home, Anthem informed Peña that he was out of network because his address had changed.
The notice “was a surprise to me because all the other insurance companies did not have any problems with that, number one,” Peña said. “Number two, why would they do this two years later after the move?”
When Peña reached out to resolve the issues, he was directed to the Availity billing platform. Information in the web platform was correct, he said, but when he tried to communicate this to Anthem he was directed back to Availity instead of being able to speak with an employee.
Since August, the clinic has not received any payments from Anthem, Peña said. The clinic is out thousands of dollars he said, though he did not have the exact number available Tuesday morning. In January, the insurance provider said that the clinic would be paid going forward, but it would not be paid for past claims.
“If they’re not going to pay it’s very bad for me and we’ll go under,” Peña said. He is now in a “quandary” over whether to continue accepting Anthem Blue Cross Blue Shield insurance which covers about a third of his patients.
The insurer is reaching out to Peña to “understand any outstanding issues and ensure they are addressed,” Turner of Anthem said.
For Bramhall, no longer taking Anthem is not an option.
“If I stop taking Anthem, there’s a lot of people who wouldn’t have the choice who have a low risk, full-term, healthy pregnancy,” Bramhall said. “They would end up having to go to a bigger hospital and it takes away choice. I’m not going to do that. I want to fix the problem.”
Anthem was the largest health insurer in New Hampshire as of the beginning of 2025, according to the state Insurance Department.
Over the past few decades, birthing options across the Twin States have steadily declined. In the Upper Valley birthing units at New London Hospital, Valley Regional Hospital, Cottage Hospital and Alice Peck Day Memorial Hospital closed between 2002 and 2018.
The only remaining hospital birthing units in the Upper Valley are at Dartmouth Hitchcock Medical Center in Lebanon and at Gifford Medical Center in Randolph.
When Bramhall opened her practice in 2021, there were five standalone birthing centers in New Hampshire. Since then, both the Concord Birth Center and the Monadnock Birth Center in Swanzey, N.H., have closed. Both cited insurance reimbursement issues as reasons for closure, according to reporting from the Keene Sentinel.
Bramhall contacted state Rep. Sue Prentiss, D-Lebanon, about her challenges in August. Prentiss has focused much of her work in the legislature on health care reform, especially maternal health care.
Prentiss has helped make some progress toward change for the clinic, including getting the insurer to assign a representative to the clinic and working with the New Hampshire Insurance Department.
“We are not in a position in any part of the state to see a freestanding option for women to deliver babies…close,” Prentiss said last Friday.
A package of legislation Prentiss sponsored last year called the “Momnibus” included $30,000 to study barriers and sustainability for independent birth centers. Though she has not heard of other providers having the exact same issues that Gentle Landing has had with Anthem, insurance issues are a known challenge.
“One of the barriers is insurance reimbursement and we have a system where something is not working between the provider and the insurer,” Prentiss said.
Since going public with her struggles last week, Bramhall has heard from residents around New Hampshire, legislators and other providers. Anthem has also started processing and paying some of Gentle Landing’s claims from as far back as April 2024.
Given the ongoing issues, Bramhall is skeptical that the progress will stick. Email exchanges show that Anthem has requested the provider update information which Bramhall said has been updated repeatedly in the past. Her long-term goal is to find a solution for all small providers in New Hampshire.
“I’m going to figure it out, but I have also heard from all of these other independent providers who are just going, ‘Us too, us too, us too, us too,'” Bramhall said. “We work really hard, small community providers are the heart and soul of health care.”