Doc-to-Doc Series: Why Anthem’s New Facility Policy Raises Red Flags Under the No Surprises Act 

By Jamie Shoemaker, MD, FACEP

Anthem Blue Cross Blue Shield (part of Elevance Health) has finalized a Facility Administrative Policy: Use of a Nonparticipating Care Provider, set to take effect January 1, 2026 in 11 states (including my state of Indiana). Under this policy:

• Hospitals that are in-network with Anthem may face a 10% reduction in reimbursement on facility claims whenever an out-of-network (nonparticipating) physician is involved in patient care. 
• Anthem may also terminate hospitals from its network if they repeatedly use out-of-network physicians.
• Anthem says this is intended to control costs and reduce misuse of the NSA’s dispute mechanisms by out-of-network providers.

Why Experts Say It Undermines the No Surprises Act

The No Surprises Act’s Purpose

The NSA is a bipartisan federal law designed to protect patients from unexpected out-of-network bills at in-network facilities, especially in emergencies or when patients cannot choose their provider. It also deliberately left room for providers and insurers to resolve out-of-network payment disputes through a structured Independent Dispute Resolution (IDR) process.

Policy Seen as Undermining Core NSA Protections

Healthcare provider groups and hospital associations contend Anthem’s new policy:

• Bypasses the IDR process that Congress created as the exclusive mechanism for resolving payment disputes between plans and out-of-network clinicians. Instead of negotiating or arbitrating pay, Anthem directly penalizes facilities for using nonparticipating clinicians.
• Essentially resurrects a “network matching” concept that policymakers rejected during NSA negotiations because it could force physicians into networks or limit patient access.
• Holds hospitals financially responsible for events beyond their control, such as staffing by independent specialists, which critics say is “unworkable” and erroneously shifts network adequacy obligations to facilities.
• Could reduce patient access, particularly in rural or underserved areas, if hospitals cannot maintain adequate specialists under Anthem’s penalties or contractual pressures.

Bipartisan / Broad Stakeholder Concerns

While most of the publicized opposition has come from healthcare providers and medical societies, the nature of the criticism reflects issues that have drawn bipartisan support in Congress for the NSA’s structure:

• Multiple physician groups (e.g., AMA, ASCP, state associations, including letters signed by dozens of organizations) argue Anthem’s policy circumvents congressional compromise embodied in the NSA and could erode the law’s intent.
• The American Hospital Association (AHA) specifically noted Anthem’s policy resembles a rejected “network matching” approach and urged Anthem to instead participate in the NSA’s IDR process. 

Recently, bipartisan members of Congress have issued public statements (12/18/25) to the tri-Secretaries responsible for implementing the NSA, asking them to investigate Anthem BCBS and this new egregious policy. The broader NSA implementation history reflects bipartisan congressional concern over preserving patient protections and preventing insurer or provider strategies that sidestep the law’s dispute mechanisms. (The NSA’s enactment itself came from a bipartisan compromise to protect patients without forcing network participation.)

How Anthem Is Attempting to Sidestep the IDR Process

Anthem’s own messaging makes clear that the policy is part of its response to the volume and outcomes of NSA disputes, which Anthem believes have been used by out-of-network providers to secure higher payments through IDR arbitration. According to Anthem/Elevance:

• Anthem sees current IDR usage, especially for scheduled non-emergency procedures, as a “back-door payment channel” that drives up costs.
• The company argues its new facility policy will reduce what it views as misuse of NSA protections and encourage more care by network clinicians. 

Critics respond that this approach essentially sidesteps the statutory IDR mechanism by imposing financial penalties instead of engaging in good-faith negotiation or formal dispute resolution, and that Anthem could already address many of its operational concerns (e.g., sharing timely information or engaging in open negotiations) without rewriting incentives. 

Bottom Line

Anthem’s new facility administrative policy:

• Penalizes hospitals for using out-of-network clinicians, a move that provider groups say undercuts the intent and mechanics of the No Surprises Act.
• Avoids the NSA’s IDR dispute process by creating a payment penalty regime rather than participating in or reforming that process.
• Has sparked widespread opposition from hospitals and physician organizations, which argue it could reduce access to care and harm independent practices.
• Touches on broader bipartisan concerns about protecting patients and respecting the negotiated balance of the NSA, though explicit congressional statements on this exact policy are still evolving.

How Ventra Health Advocacy Can Help

Ventra Health advocacy plays a critical role in addressing policies like Anthem’s facility administrative penalty by bridging frontline clinical reality with data-driven policy engagement. Ventra experts recognize that punitive measures on the facility side of the ledger will trickle down and negatively impact physicians at the bedside, ultimately affecting patient care in a deleterious way. Through best-in-class analytics, coding accuracy, and reimbursement intelligence, Ventra Health can quantify the real-world impact of insurer policies on access, staffing models, and emergency department sustainability.

Ventra’s physician strategic advisors, active bedside clinicians with deep revenue cycle expertise, are uniquely positioned to educate legislators, regulators, and stakeholders on how the No Surprises Act was intended to function and how insurer workarounds undermine its balance. By supporting hospitals and physician groups with clear data, coordinated messaging, and informed advocacy at both state and federal levels, Ventra Health helps ensure that payment disputes are resolved through the IDR process Congress designed, rather than through punitive policies that threaten independent practice, hospital-physician alignment, and patient access to emergency care.