Elevance Health has finalized a policy that will impose a 10% administrative penalty on facility claims if a non-contracted clinician is involved in the patient’s care with its Anthem Blue Cross Blue Shield commercial plans in 11 states.
Here’s five things physicians need to know:
1. Facilities are barred from shifting this penalty to patients, and repeated use of out-of-network clinicians could jeopardize the facility’s network status. The policy was finalized Oct. 1 and is set to take effect Jan. 1.
2. Three major national organizations — the American Society of Anesthesiologists, the American College of Emergency Physicians and the American College of Radiology— have jointly urged Elevance to withdraw the policy. They say the rule effectively pressures hospitals to force independent groups into the insurer’s network, regardless of local market realities or ongoing contract negotiations.
3. In their joint statement, the societies argue that the policy shifts network adequacy responsibilities from the insurer to facilities, holds hospitals financially responsible for contract decisions they do not control and could disrupt long-standing clinical teams if hospitals are pushed to reorganize coverage models
4. In a joint letter, the groups describe the proposal as “deeply flawed and operationally unworkable.”
4. Additionally, physician organizations note that the policy could undermine the existing independent dispute resolution process created under the No Surprises Act — effectively sidestepping the mechanism meant to resolve out-of-network payment disagreements.
5. Elevance says the goal is smoother care and lower costs.
“This new policy encourages care to be delivered by in-network providers while visiting in-network facilities, which helps provide a smoother member experience, improve affordability and reduce unnecessary administrative complexity,” a spokesperson told Becker’s. “Members will not see any disruption to their care. Out-of-network care will continue to be covered in emergency situations and when no options exist for in-network providers.”
