Image by Leopictures from PixabayOne of the largest health insurers in the nation is pushing a new out-of-network policy that could prove seriously challenging for ambulatory surgery centers (ASCs).
Starting Jan. 1, 2026, Anthem will penalize hospitals, surgery centers and other facilities whenever those facilities use out-of-network providers for patients covered under Anthem commercial plans. In other words, the insurer is putting financial pressure on facilities to use only in-network resources, except in certain circumstances.
Anthem published the new policy on Oct. 1.
The Ambulatory Surgery Center Association (ASCA) has been leading efforts to get Anthem to reconsider the policy. On Dec. 8, ASCA teamed up with nearly three dozen other health care organizations to oppose Anthem’s plan, highlighting key concerns in a letter to Anthem CEO Gail Boudreaux.
“Surgery centers frequently rely on contracted anesthesia, pathology and radiology groups, all of which could be in-network at the time of agreement but can fall out-of-network without notice, something ASCs have no control over,” Bill Prentice, CEO of ASCA, said in a statement.
Penalties for using out-of-network resources can vary.
In some cases, the penalty could be a 10% to all claims involving an out-of-network provider, according to ASCA. In other instances, Anthem could opt for “wholesale termination from Anthem’s network.”
“Without timely and accurate information from Anthem about changes in status of contracted providers involved in care between the time a surgery is scheduled and when it is performed, the burden of verification wrongly falls on ASCs, with significant penalties lurking behind any missteps,” Prentice continued.
ASCs in 11 states could be hit with the new policy: Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio and Wisconsin.
Scenarios where Anthem could allow for nonparticipating include emergency situations and cases where prior approval was already secured. Even so “the insurer has not made it clear how those authorizations will work or whose responsibility it will be to obtain authorization,” ASCA explained.
The other health care organizations lobbying against the policy include the American Association of Orthopaedic Surgeons, the American Academy of Ophthalmology and the American Association of Nurse Anesthesiology, plus several state-level ASC advocacy groups.
The pushback doesn’t stop there, either. Shortly after Anthem’s policy change came out at the start of October, critics began to speak out.
The American Medical Association (AMA) in a Nov. 13 letter to Anthem’s CEO said it was “dismayed” that the insurer was seemingly trying to “bypass” the No Surprises Act. AMA also emphasized the policy could hurt patients’ access to health care services.
“Care may be delayed for Anthem enrollees, as the scheduling of any procedure will be complicated by confirming only participating physicians and other providers are part of the care team,” the Nov. 13 letter stated. “It is also likely to result in fewer hospital-based physicians who are able to provide care to all patients, as hospitals push out those who do not have a contract with Anthem.”
Kara Newbury, ASCA’s chief advocacy officer, pointed to Anthem’s policy update as a key issue that ASCs need to monitor heading into 2026 during a recent Ambulatory Surgery Center News webinar.
“Payers want to make sure that they are working with in-network providers, but the No Surprises Act really also gave them a lot more leverage in negotiations,” Newbury said on the webinar. “The No Surprises Act gave them more leverage … to develop policies like what Anthem is talking about, where they’re going to penalize the facility for working with an out-of-network [doctor], anesthesia group or radiology – anything affiliated with that procedure.”
On its end, Anthem has described the policy as a way to protect patients from unexpected health care costs.
“As a participating facility in Anthem’s care provider network, your role in guiding members to in‑network care providers is vital in ensuring members receive high‑quality, cost‑effective and coordinated care,” Anthem’s Oct. 1 policy noted. “This helps protect members from unexpected costs that arise when receiving care from nonparticipating care providers in the facility‑based setting.”
As scrutiny around out-of-network billing intensifies, Anthem’s move reflects a broader shift in payer strategy aimed at tightening network control and reducing variability in episode costs.
But for ASCs, which often rely on independent physician groups and service partners they do not directly employ, the policy underscores a growing tension between payer cost-containment efforts and the operational realities of modern outpatient surgical care.
Looking ahead, if payers continue to push facility-level accountability for provider contracting, ASCs could find themselves navigating increasingly complex administrative landscapes just to maintain network participation.
