Wow… just wow. When you thought insurers couldn’t get more evil they come up with something even worse than you anticipated.
So here we have an insurer that now plans to hurt hospitals who have physicians that aren’t contracted with the insurance carrier. This has so many issues..
1) Hospitals can’t possibly figure out who is in- and out-of-network with the insurance carrier. It’s frankly not their job and it isn’t practical.
2) Physicians are going out of network due to decades of reductions in payments by both government and private payers. Anthem wants the ability to lower payments to physicians without pushback or consequence. What this leads to is every physician vertically integrating with hospitals which actually increases the costs to employers, patients, and Anthem.
3) We already have a shortage of certain specialties, in particular anesthesia. If this policy were to go through, we would see further difficulty getting surgeries for patients. Hospitalists would also likely be harder to find as many are out of network. ER physicians are too, but they are exempted in these cases
4) This will be particularly devastating to rural facilities who struggle to get coverage and in many cases are covered by locums tenens physicians who are frequently out of network
5) It’s not as easy to say “I am in network with Anthem”. There are probably 10’s of plans that Anthem administers in any given market and some of those plans are narrow networks, which means they limit the number of physicians on those networks intentionally. This means that there are physicians who are out of network by design of the insurer. Yet they will penalize the hospital for providing services to a patient whose doctor was out of network based on the decision of the insurer.
This is terrible policy and bad for everyone but the insurance company. Patients and physicians must stand together to voice our concerns.
Anthem appears to have announced that it will penalize hospitals & assess of a penalty of -10% on facility reimbursements where the hospital based physicians are out of network (OON), as of 1/1/26. Credit to Ron Howrigon and his post on LinkedIn this morning (see below).
The concept that physicians exercising rights granted to them by Congress under the federal No Surprises Act (NSA) and potentially under state laws can serve as a basis for Anthem penalizing the facilities is one that the law cannot abide IMHO.
If true and I have no reason to believe otherwise, Anthem’s actions may be federal anti-trust violations, violations of unfair and deceptive trade practices, RICO claims and I am sure that the Rs on the Ways and Means committee would be most interested in questioning Anthem.
For the state specialty societies in the states cited, and the national specialty societies, this announcement should be prioritized for possible future action.
@ACEPNation @ASALifeline @RadiologyACR @AmerMedicalAssn @texmed @CMAdocs @EDPMA @RBMAConnect @MGMA_official
linkedin.com/feed/update/urn…