Delay, Deny, Defend: Anthem’s Egregious Facility Policy Comes to New York
Many Americans, and a lot of New Yorkers, are suffering from doctor shortages and having healthcare access problems. They’re also finding it difficult to afford their care. Guess who’s trying to make everything even worse?
Big Insurance.
Effective this past Wednesday, July 1, Elevance’s Anthem Blue Cross plans have implemented their Commercial Facility Administrative Policy in New York.
New York is now the 13th state targeted by Anthem with this policy.
Since January 1 this year, Anthem has also implemented this scheme in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, and Wisconsin.
Elevance’s latest effort in New York involves using their size and effective monopoly power to pressure healthcare facilities to kick their private doctors off staff.
The policy states:
Participating facilities that have nonparticipating care providers rendering services to Anthem members in an inpatient or outpatient, facility‑based setting may be subject to the following corrective measures:
An administrative penalty equal to 7.5% of the allowed amount of the facility’s claim that involves the use of nonparticipating care providers; and
Potential termination from Anthem networks.
So, here’s what’s happening now in the nation’s fourth-most populous state.
Anthem is refusing to renew contracts with hospitals and ambulatory surgery centers (ASCs) unless they agree not to use doctors who don’t have contracts with its plans. But most independent specialists can’t get workable contracts with Anthem, or UnitedHealthcare, Aetna, or others for that matter, because they lack the size to negotiate such contracts. As such, this new policy is compels hospitals and ASCs to push their independent or “voluntary” doctors off staff.
With this move, Elevance is simply looking to further increase its market control and profits.
And here’s the kicker. With this administrative weapon a tremendous threat to patients’ continuity of care, Anthem had the audacity to raise premiums this year for its New York beneficiaries by an average 10.6%.
In May, the California Hospital Association sued Anthem to stop this scheme.
New York’s hospitals have advised the Department of Financial Services (DFS) that this policy was unlawful, but DFS declined to take action. A lawsuit is now planned in New York, too.
And other states have already enacted laws this year to block this conduct. In February, Indiana lawmakers passed Senate Bill 189 banning health insurance companies from penalizing hospitals for using out-of-network providers. This measure directly rebukes Elevance's policy in its home state. Last month, Louisiana Governor Jeff Landry signed House Bill 291 into law. Under this new law, insurers may not reduce payment or suspend or terminate a facility’s contract solely because another health professional involved in a patient’s care is out-of-network.
Proposed legislation in New York is also expected to address this latest abuse.
Anthem’s policy shifts its responsibilities under the No Surprises Act to hospitals and other facility-based providers, effectively shirking its responsibility to negotiate and contract with medical providers in good faith and with fair terms to ensure adequate in-network access to care for its members.
This scheme is already causing harm to patients, doctors, hospitals, and ASCs. Experienced doctors are moving out of New York or just simply retiring. Patients are being forced to wait months for appointments with specialists, and, even then, may not get to see the doctor they really need. Already strained, hospitals and ASCs are being pushed to the brink and forced to pull back on needed medical programs.
Giant health insurance corporations like Elevance already generate billions of dollars in annual profits and pay its CEO an eight-figure pay package. Their anti-patient and anti-competitive behavior, perfectly embodied in this policy, needs immediate attention from more legislatures and regulators nationwide.