ACR blasts ‘deeply flawed’ Anthem policy targeting out-of-network radiologists
The American College of Radiology and other medical societies are blasting a new Anthem policy that punishes hospitals for using out-of-network radiology providers.
Last month, the insurance giant announced it will begin charging a 10% administrative penalty for claims that involve docs outside of its networks. The policy is slated to take effect on Jan. 1, with Anthem (aka Elevance Health) also threatening to knock hospitals OON if they use such providers.
ACR, the American Society of Anesthesiologists and the American College of Emergency Physicians recently wrote to Anthem on this issue, expressing their “strong opposition.” They’re requesting a meeting with the Indianapolis-based company to discuss their concerns.
“This policy is deeply flawed and operationally unworkable,” the three societies wrote to Elevance Health President and CEO Gail Boudreaux, MBA, on Nov. 5. “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.”
ACR, ASA and ACEP—which previously have banded together on issues related to surprise medical billing—believe this policy will force hospitals to compel docs into joining Elevance’s network. They’ll likely do so under “unfavorable terms,” leading to the risk of “worsening financial instability and loss of clinicians,” the groups contend. Forcing hospitals to reorganize or replace physician groups to honor the new policy likely will “jeopardize” continuity of care and patient access, they believe.
“Provider staff privileging decisions are based on quality, competence, and credentials—not insurance participation,” they added. “Expecting facilities to monitor and enforce payer contracts across dozens of independent entities and multiple commercial plans is not only impractical but raises serious legal and ethical concerns.”
ACR et al. are urging Elevance/Anthem to “immediately reconsider the policy.” They’re also pushing for a meeting with the payer’s leadership to discuss its implications and “advocate for a more sustainable and collaborative approach to network adequacy and provider contracting.”
The college highlighted the letter in a news update published Monday. In it, ACR labeled the policy update as a “a blatant attempt to subvert” the federal No Surprises Act, which was created to protect patients from unexpected medical bills. It emphasized that the NSA already provides a “fair and balanced mechanism” to resolve disputes between insurers and payers over out-of-network care.
“Network adequacy is the responsibility of insurers, not hospitals, and is a fundamental element in incentivizing good-faith negotiations between physicians and insurers,” ACR added.
Elevance Health shared a statement last month with Radiology Business in response to criticisms about the policy. Several clinical scenarios are exempt from the change, including emergency services, cases where the payer has granted prior authorization, and in instances where no in-network provider is available.
“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,” an Elevance representative said Oct. 23. “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.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.