Managers of Anthem Blue Cross think that in-network hospitals in California should use in-network physicians to treat health plan participants.
The Elevance Health subsidiary announced earlier this week that it will impose a 10% payment penalty on some in-network hospitals and other health care facilities that bill patients for care provided by out-of-network doctors.
“Participating facilities may not balance bill members for any such reduction in payment,” Anthem said.
In some cases, Anthem said, it may exclude facilities that repeatedly bill for care furnished by out-of-network providers from its provider networks.
The penalty policy is set to take effect June 1.
The policy is similar to one Anthem began applying Jan. 1 in Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio and Wisconsin.
Anthem said in a notice to California facilities that the policy will help keep patients who use in-network care from getting surprise medical bills.
“Your role in guiding members to in-network care providers is vital in ensuring members receive high-quality, cost-effective and coordinated care,” Anthem said.
The Anthem surprise doctor penalty scope: The Anthem surprise doctor penalty will apply only to care for patients covered by self-insured employer health plans.
Anthem will not apply the penalty to emergency care, to rural hospitals, or to the “safety-net” hospitals that tend to treat a high percentage of low-income patients.
Anthem will also avoid applying the penalty when a hospital is using an out-of-network doctor because no in-network doctor in the hospital’s area can provide the same services.
Pushback: Health care providers are not happy with the idea of payers penalizing facilities for using out-of-network physicians to deliver care.
In Indiana, Elevance Health’s home state, members of the Indiana Senate recently voted 49-0 to approve Senate Bill 189, a bill concerning how payers pay for out-of-network care. One section “provides that if a health carrier assesses a facility or a provider an administrative fee or penalty related to the provision of care to an individual that involves an out-of-network provider, the health carrier commits an unfair and deceptive act or practice in the business of insurance,” according to the official bill digest.