Anthem to Target Participating Facilities Using Nonparticipating Providers

Anthem recently announced that effective January 1, 2026, it intends to reduce reimbursement and may terminate commercial network agreements with participating facilities that continue to use nonparticipating providers to treat Anthem members. Anthem identifies participating facilities in Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, and Wisconsin, as subject to "an administrative penalty equal to 10% of the allowed amount of the facility's claims that involve the use of nonparticipating care providers." Facilities may also face network termination.

Notably, the 10% reimbursement reduction is not linked to the actual charges for a nonparticipating care provider's services. Instead, Anthem's announcement indicates it will apply the 10% reduction across the board when a participating facility uses a nonparticipating care provider "for any component of the member's care."

Facilities may have contractual rights to object to Anthem's intent to use "administrative penalties" to reduce contractual reimbursement. State laws may also afford certain protections. Please contact John Barnes or Leslie Murphy from DWT's healthcare practice group if you would like to discuss further.