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Anthem Blue Cross and Blue Shield — a unit of Elevance Health — will use a new 10% administrative penalty to discourage in-network hospitals and other in-network facilities from using out-of-network providers to care for patients.
Anthem's commercial plans may deduct the penalty from their allowed amounts for claims that involve the use of out-of-network providers, and it may cut facilities that use out-of-network providers out of its provider networks.
The Anthem plans will not apply the penalty to emergency care or to cases of use of out-of-network care that have received prior approval from Anthem.
A notice describing the penalty says it will take effect Jan. 1, 2026, for in-network facilities in Colorado, Connecticut, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio or Wisconsin.
The notice does not mention some other states in Anthem's market area, such as New York.
"We are implementing this policy to encourage care to be delivered by in-network providers while visiting in-network facilities," the company said in a statement about the new penalty policy. "This will help ensure a smoother member experience, improve affordability, and reduce unnecessary administrative complexity. 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."
What it means: The fight over out-of-network billing seems to be heating up.
Out-of-network billing: Employers and benefits brokers have complained for years about health plan participants going to in-network hospitals and ending up with expensive bills from out-of-network providers, such as anesthesiologists and emergency care physicians.
The federal No Surprises Act is supposed to reduce the odds that patients will be "balance billing" for unexpected out-of-network bills, but insurers and plans are still getting the surprise bills and must negotiate over the amounts through a new dispute resolution process created by the act.
The backdrop: The ERISA Industry Committee told the Internal Revenue Service in June that providers have been using No Surprises Act processes to increase reimbursement levels.
Groups for anesthesiologists and other providers who often startle patients by sending out-of-network bills say the out-of-network bills are mainly the result of unrealistically low health insurer and health plan reimbursement rates for some types of care.
The administration of President Donald Trump could be sympathetic to that view, because Lori Chavez-DeRemer, the current secretary of the U.S. Department of Labor, is the wife of an anesthesiologist.
Chavez-DeRemer oversees the Labor Department's Employee Benefits Security Administration, which works with other federal agencies to regulate employer health plans.
Catalyst for Payment Reform contends that third-party administrators and other players have an incentive to keep out-of-network reimbursement rates realistically low, to increase compensation tied to the size of the discounts they negotiate.
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