Elevance to penalize facilities for out-of-network providers

Modern Healthcare – Friday, October 24, 2025
By Nona Tepper

Elevance Health has notified healthcare facilities they face penalties for assigning out-of-network clinicians to its members.

Starting Jan. 1, hospitals and other inpatient and outpatient facilities must ensure that all providers involved in care for members of Elevance Health’s Anthem Blue Cross Blue Shield commercial plans in 11 states are under contract with the insurer, Anthem said in a notice.

Facilities that don’t comply may be assessed administrative penalties equivalent to 10% of the allowed amounts payable under the claims in question, and may be terminated from Anthem networks. Facilities are not permitted to pass the cost of administrative penalties on to patients.

“We are committed to ensuring appropriate use of nonparticipating care providers in the facility-based setting in the care of our members. 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,” Anthem wrote.

Emergency care is exempt, as are services for which Anthem previously approved an out-of-network provider’s involvement. The policy applies in Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio and Wisconsin.

“We are implementing this policy to encourage care to be delivered by in-network providers while visiting in-network facilities. This will help ensure a smoother member experience, improve affordability and reduce unnecessary administrative complexity,” Elevance Health said in a statement. “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.”

The American Hospital Association is still reviewing the Elevance Health policy and is “concerned,” a spokesperson wrote in an email.

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