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New Anthem Policy to Punish Facilities for Use of Out-of-Network Providers

This rule circumvents federal surprise billing protections and could penalize ASCs

BY STEPHEN ABRESCH | DECEMBER 3, 2025

ASCs could experience financial strain from Anthem’s new commercial facility administrative policy for out-of-network providers. Anthem published the new policy on October 1, and it would affect both hospitals and surgery centers.

Effective January 1, 2026, facilities participating with Anthem that use nonparticipating providers who do not have a contract with Anthem and provide services to Anthem members in an inpatient or outpatient facility setting may be subject to corrective measures, which can include: an administrative penalty equal to 10 percent of the allowed amount of the facility’s claims involving nonparticipating providers; and potential termination from Anthem’s networks. The policy will affect Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio and Wisconsin. Exceptions include emergency services, and instances when Anthem has granted prior approval for use of a nonparticipating provider and where no participating provider is available to render the same services within a geographical area.

Surgery centers frequently rely on contracted anesthesia, pathology and radiology groups, all of which could be in-network at the time of agreement but can fall out-of-network without notice, something ASCs have no control over. Without more robust communications from Anthem that ensure ASCs have accurate information about contracted providers involved in care between the time a surgery is scheduled and when it is performed, the burden of verification falls squarely on ASCs, with significant penalties lurking behind any missteps.

In a Fierce Healthcare report about the new policy, Ariel Bayewitz, vice president of Health Economics at Elevance Health, Anthem’s parent company, said the policy is designed to address provider behavior under the No Surprises Act’s (NSA) independent dispute resolution process (IDR). Bayewitz stated that Anthem has seen a pattern of IDR being used as a way for out-of-network providers to secure higher reimbursements for nonemergent procedures. “These cases, by and large, are not surprise bills,” he said, describing what he views as a trend of planned procedures from out-of-network providers at in-network hospitals being pushed toward IDR. “They are planned surgeries, they are nonemergent. They’re things like spinal surgeries, plastic surgeries in markets where we have very robust networks.”

In his remarks, Bayewitz singled out breast reduction surgery as a high-impact code in IDR disputes, highlighting Connecticut, where the average physician award from IDR for the procedure is $60,000, versus $1,145 that Medicare reimburses for the same procedure in the state. “When you look at what they’re getting paid, it’s significantly higher than market rates, and in some cases even higher than their own bill charges,” Bayewitz said.

Anthem’s explanation that the policy is aimed more at hospitals and is in response to IDR awards related to a handful of procedures belies the fact that the policy itself is far broader, applying to inpatient and outpatient settings—including ASCs—for any services provided to Anthem beneficiaries by any nonparticipating providers, not just physicians.

Since the new policy was announced, provider organizations have pushed back forcefully. In their November 5 letter to Anthem the American Society of Anesthesiologists (ASA), the American College of Radiology (ACR) and the American College of Emergency Physicians (ACEP) asked Anthem to rescind the policy immediately. The letter describes the policy as, “deeply flawed and operationally unworkable,” and notes that, “it effectively shifts Elevance’s network adequacy obligations onto facilities, holding them financially liable for the contracting status of independent physician groups—an area over which they have no control or infrastructure to manage.” The organizations also note that provider staff privileging decisions are based on quality, competence and credentials, not insurance participation, and that making facilities monitor and enforce payer contracts raises legal and ethical concerns.

The American Medical Association (AMA) submitted a letter to Anthem on November 13 also urging the immediate rescission of the policy. State medical associations and other provider organizations like the American Association of Orthopaedic Surgeons (AAOS) and the American Gastroenterological Association (AGA) signed the letter. The AMA questioned the policy as an attempt to bypass the provisions of the NSA that protect patients from surprise medical bills when out-of-network care is provided at an in-network facility, noting, “Though many surprise billing proposals were debated during the NSA negotiations, Congress landed on a policy that did not compel or push physicians into all health insurance networks but rather focused on patient protections and fair payment. We find it very concerning that rather than working through the NSA, Anthem is choosing to implement a policy that essentially circumvents the statute.” The AMA letter also highlighted how the policy could negatively impact patient access to care, noting it could inadvertently raise hospital costs, delay care for Anthem beneficiaries and restrict the number of hospital-based physicians who can provide care to all patients, a significant issue for patients in rural areas.

Despite the opposition, Anthem has not shown any signs of rescinding or delaying the new policy before its January 1, 2026, effective date. If implemented, there is little preventing Anthem from expanding the policy to impact other states, or other insurers from following Anthem’s lead.

ASCA is working with provider organizations and state ASC associations to prevent the implementation of this policy and ensure that ASCs are not used by Anthem as an avenue to pressure healthcare providers to accept Anthem contracts.

To learn more about this and ASCA’s efforts to oppose the policy, write Stephen Abresch at sabresch@ascassociation.org.