Anthem expanding policy that punishes hospitals who use out-of-network radiologists
Anthem Blue Cross and Blue Shield is expanding a controversial policy that punishes hospitals who use radiologists and other physicians outside of its networks.
The insurer first launched its new “nonparticipating care providers” policy across 11 states beginning on Jan. 1, drawing widespread criticism from the House of Medicine. With it, Anthem is levying a 10% administrative penalty of the allowed amount for hospital claims that involve out-of-network rads.
The insurer is now spreading the policy to a 12th state, California, beginning on June 1.
“To support patient care and to help reduce out‑of‑pocket expenses…it is essential that members of self‑funded plans are directed to care providers participating in our Anthem network,” BCBS (also known as Elevance Health) said in a March 1 notice to the healthcare industry.
Previous states impacted by the nonparticipating provider policy include Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio and Wisconsin. However, Hoosier State Gov. Mike Braun recently signed Senate Bill 189 into law, stopping Anthem from implementing the policy there. The measure was supported by the Indiana Physicians Health Alliance (IPHA), state medical association and numerous others.
IPHA said it believes Anthem’s policy will have unintended consequences on independent doc groups in radiology and other specialties, who depend on hospital relationships.
“Patient care may be impacted in circumstances where the best medical option for the patient is an out-of-network independent physician,” Steve Freeland, board officer of IPHA and CEO of Cancer Care Group, a radiation oncology provider based in Indianapolis, said in a statement prior to SB 189 passing. “We strongly encourage Elevance to rescind this policy and work with providers and legislators to find reasonable solutions that address the concerns of providers and Elevance,” added the IPHA, whose members include Northwest Radiology and Radiology of Indiana.
More on California
Like the original policy in the first 11 states, Anthem is threatening termination from its networks for California hospitals who use out-of-network physicians. It also will forbid participating facilities from passing the 10% penalty onto patients. The nonparticipating provider penalty pertains to in- or outpatient settings.
However, it excludes emergency services, cases where Anthem has granted prior approval, instances where no in-network provider is available in the geographic area, and for certain smaller hospitals. Elevance/Anthem, whose health plans and other companies serve over 104 million consumers, did not mention the No Surprises Act in its notice. However, radiologists charge its implementation of this policy is directly in response to battles with providers over the landmark legislation.
Patients are already protected from paying higher care costs thanks to the No Surprises Act. This means they will not save money from the Anthem policy with it only benefiting Elevance, Indiana physicians charge, at the expense of providers and access to care.
Indianapolis-headquartered Elevance in December said it agrees the NSA has fulfilled its primary purpose. However, it believes the law also has created incentives for many physicians to remain out of network due to the “extremely high, unsustainable” payment amounts they were winning through the legislation. NSA is centered around letting physicians and payers resolve payment disputes using an independent third party. However, docs have been prevailing at high rates, winning payments much higher than insurers’ first offer.
“Instead of resolving disputes with independent arbiters through the federal process … [Anthem’s new policy] shifts financial pressure onto hospitals and risks disrupting patients’ access to care,” Nashville, Tennessee-based Rad Partners, the country’s largest imaging group, which operates in California and Indiana, told Radiology Business in a statement Wednesday. “It’s an end-run around a bipartisan solution that has been in place for several years. Even Indiana, Anthem’s home state, has already banned this practice, which underscores just how far this policy goes beyond the bounds of reasonable payer behavior.”
RP CEO Rich Whitney, MBA, also criticized the California expansion in a social media post March 11, believing the new Anthem policy will be challenged in the courts. Wendell Potter, former VP of Cigna and a “reformed insurance propagandist,” wrote this week about how insurers like Elevance have already started using the judicial system to “intimidate physicians, rewrite the [NSA] and consolidate control.”
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.