Prioritize Protecting Patients' Timely Access to Care, Not Padding Insurer Margins

Patients are best served when insurers act as transparent and reasonable partners, not when they invoke patient protection laws to justify payment strategies that harm the very patients they were designed to protect.

Anthem Policy Limits Patients’ Access to Care

When patients need care, it can feel like navigating an impossible maze of red tape. Many plans require members to find an in-network provider, secure prior authorization for medically necessary treatment, and explore layers of cost-sharing requirements to understand their financial responsibility. At the end of that maze, they trust that insurers will cover the care that they have been dutifully paying premiums for, and that insurers and providers will handle payment disputes professionally behind the scenes, without disrupting patient care.

That’s the promise of the No Surprises Act, which created the Independent Dispute Resolution (IDR) process to help insurers and providers reach an agreement over payment disputes. But Anthem’s new nonparticipating provider facility policy shows how far its policies stray from that goal. It would force in-network hospitals to bear the financial penalty if any physician involved in an Anthem member’s care is out of network. In practice, Anthem would reduce the hospital’s payment by 10%, even when the hospital does not employ that physician or control the physician’s network status.

Anthem Evades Its Responsibility to Contract with Clinicians in Good Faith

Anthem claims the policy is needed to protect patients and employers from rising costs tied to alleged abuses of the federal IDR process. But Anthem’s own implementation tells a very different story. This policy appears to be far less concerned about addressing the No Surprises Act or a “few bad actors,” and far more focused on using the law as a pretext to cut payments to hospitals that negotiated in good faith to participate in Anthem’s networks to offer patients more access to care. Anthem’s implementation may protect the insurer’s margins, but it does not protect patients.

Anthem Policy Overreaches

Anthem has implemented this payment cut broadly, even in instances in which the federal IDR process isn’t available. That distinction matters. The No Surprises Act does not replace state laws that already protect patients and determine the total amount that insurers must pay providers. For example, Anthem is broadly enforcing the policy in the fully insured and self-insured coverage markets in Connecticut and Colorado, even though, in the fully insured market, both states have established laws protecting patients and determining how much insurers must pay providers. In these instances, providers cannot even access the federal IDR process that Anthem claims is being abused. Yet Anthem still applies the same payment reductions to hospitals in these states regardless of whether federal IDR is available at all. That inconsistency is revealing.

For patients, this matters. When insurers unilaterally slash payments to network hospitals, it creates financial instability that can ripple through the care system, affecting staffing, services and the availability of specialists.

A recent Anthem op-ed defending its policy points to recently enacted legislation in Indiana as evidence that policymakers are working to “restore balance” to the system. What Anthem leaves out is crucial: Indiana’s law explicitly prohibits the very types of penalties Anthem is imposing on hospitals. Policymakers there recognized that resolving disputes should not come at the expense of access to care or fair contracting practices.

Using the No Surprises Act as cover for broad payment cuts does not restore balance. It erodes trust, destabilizes care delivery and ultimately threatens the access patients depend on.