Anthem’s New Penalty Policy Targets Out-of-Network Billing at In-Network Facilities

November 6, 2025

Quick Summary

Anthem will impose a 10% administrative penalty on facilities that use out-of-network providers, starting Jan. 1, 2026.
The policy applies in 11 states and may result in network termination for non-compliant facilities.
Emergency and pre-approved out-of-network care are exempt.
The move responds to concerns about the misuse of the No Surprises Act’s IDR process.
Hospitals and provider groups are pushing back, citing legal, economic, and operational concerns.

Anthem Blue Cross and Blue Shield (a unit of Elevance Health) has introduced a policy that could significantly impact how in-network hospitals work with out-of-network physicians. Starting January 1, 2026, Anthem will impose a 10% administrative penalty on the allowed amount for any claim involving out-of-network providers—unless the care qualifies as emergency or has been pre-approved.

This policy will apply to Anthem’s commercial plans in 11 states: Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, and Wisconsin. Anthem also warned that hospitals continuing to use out-of-network providers may be removed from its network.

According to Anthem, the goal is to improve affordability, reduce administrative complexity, and ensure smoother patient experiences. However, the announcement has already raised concerns among healthcare providers, with many saying the move could lead to legal challenges under the No Surprises Act (NSA).

Concerns from the Provider Community

Hospitals and provider groups argue that Anthem’s policy may violate both federal and state laws, which permit the use of nonparticipating physicians in certain settings. Critics also suggest the new penalty could constitute antitrust or deceptive trade practice violations.

Anthem says the policy responds to providers allegedly exploiting the NSA’s Independent Dispute Resolution (IDR) process to route planned procedures through arbitration for higher reimbursement. The insurer cited examples such as spinal and plastic surgeries, performed in regions with ample in-network provider access.

The company pointed to outsized IDR awards, including breast reduction surgeries in Connecticut, where providers reportedly receive as much as $60,000—compared to Medicare’s rate of around $1,100.

Industry and Regulatory Implications

Attorneys and specialty societies are now closely monitoring the policy’s implications. Radiologists, anesthesiologists, and other hospital-based specialists worry the policy could disrupt care access and contract relationships.

At the same time, employer groups have voiced support, noting that self-funded employers absorb nearly 90% of IDR-related costs. The ERISA Industry Committee and other advocates say unchecked payouts will translate into higher premiums and employee cost-sharing.

Why This Matters

Anthem’s policy could disrupt how hospitals and physician groups work together, particularly for elective procedures. Providers in affected states must evaluate their networks, compliance protocols, and referral structures.

With the NSA continuing to evolve, understanding new payer policies is essential for protecting reimbursement and operational continuity.

Need Help Navigating the Changes?

If your organization contracts with out-of-network providers or is impacted by evolving NSA enforcement, Patriot Group can help.