Elevance Health, through its Anthem plans, is broadening a “nonparticipating provider” policy that penalizes in-network hospitals when out-of-network clinicians are involved in non-emergent care for Anthem members. This policy has significant implications for gastroenterologists and endoscopy units, particularly those performing advanced GI procedures common in ASGE member practices.
Key Issues:
- In-network facilities can see payment reductions of about 10 percent on claims that include out-of-network clinicians.
- Repeat use of out-of-network physicians may expose hospitals to network termination risk.
- The policy, initially launched in 11 states (Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, and Wisconsin), is now being expanded to additional markets and products, including in California and to more commercial / self-funded plans.
Elevance argues the policy is intended to steer patients to in-network care and to curb what it views as misuse of the No Surprises Act dispute resolution process.
Why ASGE is Concerned
ASGE and other physician organizations have already urged Elevance Health to rescind or modify this policy, citing risks to patient access and physician autonomy.
For gastroenterologists, especially those performing complex and hospital-based procedures (ERCP, EUS, advanced polypectomy/ESD, bariatric endoscopy, emergent GI bleeding interventions), the policy raises several concerns:
- Pressure on independent GI groups: Hospitals face financial and network risk when out-of-network GI physicians are involved in care, creating strong incentives to require those physicians to join Elevance networks or risk losing access to hospital ORs, endoscopy units, or on-call schedules.
- Threats to call coverage and complex on-call services: Safety-net and tertiary hospitals often rely on mixed on-call panels, including out-of-network GI specialists for advanced or emergent procedures. Penalizing hospitals for using those specialists could destabilize coverage, particularly nights and weekends.
- Impact on referrals and centers of excellence: Referring physicians and facilities may avoid directing patients to high-volume GI centers of excellence if any of the key endoscopists are out-of-network, even when those centers offer the best outcomes for complex procedures.
- Undermining negotiated out-of-network use: Patients who knowingly seek care from an out-of-network GI specialist—based on expertise or prior relationship—may find hospitals increasingly reluctant to accommodate those choices because of the penalty risk.
Policy and Advocacy Context
Hospitals, specialty societies, and state medical associations are pushing back:
- The American Hospital Association and others have warned that the policy effectively punishes hospitals for physician network status they often do not control and could mislead patients about where they can safely access care.
- ASGE and peer physician organizations have raised concerns that Elevance’s approach is inconsistent with the spirit of the No Surprises Act and could reduce access to necessary GI care, particularly for complex and emergent cases.
- Some states are already responding. For example, Indiana passed legislation to block implementation of Elevance’s 10 percent out-of-network hospital penalty, signaling potential for broader state-level pushback.
Practical Implications for GI and EndoscopyASGE members may see effects across several domains:
- Contracting and credentialing: Independent GI groups may face increasing pressure from hospitals to join Elevance/Anthem networks or risk changes to privileges, block time, or call arrangements.
- Program design for advanced endoscopy: Hospitals may reconsider how they structure advanced endoscopy programs and multi-specialty collaborations if involvement of any out-of-network proceduralist can trigger a facility-level penalty.
What ASGE Members Can Do
ASGE practices and hospital-based GI leaders should consider:
- Reviewing contracts and policy language with Elevance/Anthem and with their hospitals to understand when and how penalties apply.
- Engaging with hospital administration to discuss the value of advanced GI and on-call services, and to ensure GI is represented in any institutional response to the policy.
- Supporting ASGE advocacy by sharing de-identified examples of how the policy affects access, coverage, and patient care, to strengthen ASGE’s policy and regulatory engagement.
- Coordinating with state medical societies and GI coalitions in states where the policy is expanding, particularly where legislative or regulatory solutions may be considered.
ASGE will continue monitoring Elevance’s implementation, collaborating with other physician organizations, and advocating for policies that preserve patient access to high-quality GI and endoscopic care while ensuring fair and sustainable contracting frameworks for physicians and hospitals.