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Providers prepare to fight Anthem's new out-of-network policy

Over 80 physician groups oppose an upcoming Anthem policy that penalizes hospitals when members receive care from an out-of-network provider in the facility setting.

Jacqueline LaPointe
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Published: 19 Nov 2025

Physician groups are speaking out against an upcoming Anthem policy that would penalize hospitals for using providers not within the payer's network.

Anthem announced the "Facility Administrative Policy: Use of a Nonparticipating Care Provider" policy in October 2025. The policy states hospitals could face an administrative penalty equal to 10% of their allowed amount on facility claims or potential termination from Anthem's networks if contracted facilities use out-of-network providers for their members.

The policy will apply to services members receive in inpatient and outpatient facility settings and will roll out as of Jan. 1, 22026, in 11 states -- Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio and Wisconsin.

However, over 80 specialty physician and state medical associations, including the American Medical Association, opposed the policy in a national federation letter to Elevance Health, the parent company of Anthem Blue Cross.

The letter explained that the policy "attempts to use hospitals as a conduit to pressure physician practices either to accept Anthem contracts that may not support their continued sustainability or push them into employment, while reducing access to care for patients."

The policy could be especially troubling for independent physicians and specialists, as hospitals are unlikely to absorb the 10% reimbursement cut. Instead, hospitals will likely pass that cost on to physicians through contracts or pressure them to join networks with unfavorable terms, the letter explained.

Independent physicians are already under pressure to consolidate and join hospital networks as their financial stability and sustainability are under threat. This has led to challenges in patient access to care, in addition to higher overall healthcare costs.

The California Medical Association, which signed the letter, added in a separate statement that, while application of the policy is limited in the U.S., the policy sets "a troubling precedent for other states."

Instead of implementing the policy, the national federation letter advised Elevance to consider alternatives that incentivize participation in their networks, such as "offering fair and competitive contracts that allow physician practices to employ appropriate staff."

The letter also urged the removal of prior authorization requirements, faster credentialing, fewer denials of medically necessary care, more robust referral networks and streamlined payment processes.

In the policy announcement, Anthem said that it is "committed to ensuring the appropriate use of nonparticipating care providers in the facility-based setting in the care of our members."

It's no surprise -- medical bill, that is

The upcoming Anthem policy harkens back to the No Suprises Act (NSA), a federal law that seeks to protect patients from unexpected medical bills, particularly those stemming from out-of-network care.

Specifically, the NSA prohibits balance billing for certain services furnished by out-of-network providers. Therefore, since its enactment in 2020, payers have had to cover some services -- mostly emergency -- when a patient is unable to give authorization for out-of-network provider treatment. This has led to significantly more payment disputes with providers, resulting in over 3.3 million disputes formally lodged through the NSA's independent dispute resolution process.

Providers involved in NSA payment disputes tend to win, with about 84% of cases going to providers, according to data released earlier this year by HHS' Center for Consumer Information and Insurance Oversight.

The physician groups and state medical associations signing the letter to Elevance said Anthem's new nonparticipating provider policy stems out of the NSA. However, it undermines the patient protections Congress intended to enact.

"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," they stated in the letter. "We find it very concerning that rather than working through the NSA, Anthem is choosing to implement a policy that essentially circumvents the statute."

Anthem did carve out exceptions to its policy, including when providers furnish emergency services and when the payer has granted prior approval to use a nonparticipating provider. The policy also states that participating providers may not balance-bill members for administrative penalties applied to facility claims when the policy is violated.

Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.

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