Anthem expands policy that punishes hospitals who use out-of-network radiologists into new state
Anthem is expanding its controversial policy, targeting hospitals who use out-of-network radiologists or other physicians, into New York state.
The insurer (also known as Elevance) 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 began levying a 10% administrative penalty of the allowed amount for hospital claims that involve out-of-network rads.
Anthem expanded the policy to California in March and is now adding New York as the 13th state, effective July 1. Different from others, the insurer is charging 7.5% of the allowed amount there.
“We are committed to ensuring the appropriate use of nonparticipating care providers in the facility-based setting for … our members,” Anthem said in an April 1 notice. “This is especially important when a member receives care at a facility during an inpatient stay or an outpatient procedure, and that facility uses a nonparticipating care provider for any component of the member’s care.”
Previous states impacted by the 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, state medical association and numerous others.
Like the original policy in the first 11 states, Anthem is threatening termination from its networks for New York hospitals who use out-of-network physicians. It also will forbid participating facilities from passing the 7.5% penalty onto patients. The punishment pertains to both 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. But radiologists believe the policy is directly in response to battles with providers over the landmark legislation.
The American Hospital Association also recently voiced its opposition to the Anthem’s changes in an editorial published by Healthcare Dive.
“Framing this as an altruistic gesture that protects patients, the timing and draconian penalties for hospitals for noncompliance suggest something far more cynical, and that is Anthem’s desire to avoid what it sees as flaws in the No Surprises Act and specifically the law’s independent dispute resolution process,” AHA CEO Rick Pollack wrote March 26. “The new policy launched Jan. 1 threatens to cut hospital payments by 10% or even remove the hospital from its network if it fails to comply. Upon closer look, this policy appears designed to pressure independent physicians into contracting with Anthem on its terms and force hospitals to serve as Anthem’s enforcement arm—an unethical and impossible mandate on both fronts.”
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.