Anthem’s upcoming facility administrative policy limiting the use of out-of-network clinicians at participating hospitals is drawing sharply different reactions from orthopedic leaders who agree on protecting patients, but diverge on how best to get there.
Kevin Bozic, MD, chair of surgery and perioperative care at Dell Medical School at The University of Texas at Austin, called the move “bold” and “very patient-centered,” saying it reflects a genuine attempt to reduce surprise bills and encourage coordinated, high-quality care.
“If I’m a patient, I don’t want to get care and later find out that some of the people on my care team were out of network, and I’m stuck with a surprise bill,” Dr. Bozic said.
Effective Jan. 1, the policy allows a 10% administrative penalty on facility claims involving nonparticipating clinicians and, in some cases, the ability to remove facilities from its network. It prohibits balance billing patients and aims to steer members toward in-network care to help lower out-of-pocket costs.
Dr. Bozic said the policy should have little impact on integrated health systems where all clinicians operate under one network or organization. But he acknowledged it could create challenges in fragmented settings where hospitals contract with independent physician groups under different tax IDs.
“When you have different clinicians with different tax IDs coming together to provide care, it can create coordination challenges,” he said. “I’m a firm believer that greater alignment among providers leads to better communication and outcomes for patients.”
He noted that rural hospitals, which sometimes rely on specialists who are not part of the core team, could face access challenges if those clinicians are out of network.
While Dr. Bozic said he believes the policy has a sound rationale, others see it differently. Adam Bruggeman, MD, a spine surgeon at Texas Spine Care in San Antonio, called the rule “heavy-handed” and “anti-competitive.”
“Congress already addressed this issue through the No Surprises Act to protect patients,” Dr. Bruggeman said. “This feels like a way for insurers to sidestep that process, rather than work within it.”
He warned the policy could disrupt coverage for hospitals that depend on independent anesthesia, hospitalist or consulting groups whose network status can change during negotiations.
Dr. Bruggeman said hospitals could face penalties if independent groups that provide patient care go out of network with Anthem, even when those contract negotiations are outside the hospital’s control.
He added that rural hospitals could be hit hardest, since many rely on locum-tenens and other contract physicians who are often out of network. He noted that many rural communities already struggle to find in-network specialists, and that additional penalties could further limit patient access.
Dr. Bruggeman also questioned whether enforcement will be consistent.
“Do we really think Anthem is going to go after large systems like HCA and Ascension,” he said, “or after smaller, physician-owned facilities that don’t have the legal or financial resources to fight back?”
Dr. Bozic acknowledged those risks but said the policy could still advance alignment around value-based care if implemented thoughtfully.
“Every decision in healthcare should be viewed through the lens of delivering better outcomes that matter to patients with the resources we have,” he said.
Dr. Bruggeman agreed that patient protection should remain the focus but said the better path is to fix inefficiencies in how the No Surprises Act is administered rather than add new restrictions.
He said insurers and physicians should stop turning to lawsuits and instead improve transparency and data sharing so the system works as intended.
As the policy’s Jan. 1 start date approaches, hospitals, physicians and payers will be watching whether Anthem’s approach leads to tighter integration and fewer surprise bills — or new challenges for coverage and access, especially in smaller or rural settings.
