LUGPA Policy Brief: Anthem’s New Non-Participating Provider Policy and Its Impact on Urology Practices

December 2025

Anthem Blue Cross Blue Shield, part of Elevance Health, will implement a new policy on January 1, 2026, penalizing participating hospitals and outpatient facilities that use non-participating providers in inpatient or outpatient settings across 11 states. Facilities referring Anthem members to out-of-network clinicians without prior authorization will face a 10% administrative penalty on claims and may be removed from Anthem’s network for repeated violations.

The policy, framed as a cost-control measure, applies in Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, and Wisconsin. Exceptions include emergency services, prior-approved cases, and (in some states) situations where no in-network provider is reasonably available. Facilities are prohibited from passing penalties to patients.

This is the first major insurer policy to directly penalize out-of-network referrals. If deemed successful, other payers may follow. Elevance claims inaccurate provider directories and inappropriate referrals drive higher costs, a point long disputed by providers.

Key Implications for Urology Practices

1. Disrupted Referral Pathways
Hospitals and ASCs may restrict referrals to non-participating urologists to avoid penalties. This threatens access to high-skill specialists, especially in rural areas where in-network options are limited and geographic exceptions require burdensome documentation.

2. Administrative and Financial Pressure
Though penalties target facilities, urology practices may face indirect pressure to renegotiate contracts or alter workflows. This comes amid rising denials, stricter prior authorization requirements, and ongoing Medicare/Medicaid reimbursement reductions.

3. Increased Network Fragmentation
Provider backlash may prompt some hospitals or large specialty groups to leave Anthem networks, reducing patient volumes and increasing uncompensated care for remaining practices. Others may have to accept lower rates or tighten utilization controls.

4. Patient Access Risks
While reducing surprise billing, the policy may limit patient choice and delay care for time-sensitive conditions such as prostate cancer, renal masses, or severe stone disease.

Analysis

• Cost Control vs. Provider Burden: Critics argue the policy shifts responsibility to facilities and specialists instead of fixing inadequate networks or outdated directories.
• Precedent-Setting: As the first penalty-based out-of-network referral policy, it could influence broader commercial market trends.
• State Variation: Differences in exception criteria offer opportunities for targeted advocacy, particularly in areas with limited urology access.

Recommendations for LUGPA Members

1. Assess Exposure
Review Anthem contracts, referral patterns, and points where out-of-network clinicians are used. Identify where exceptions or pre-approval may apply.

3. Strengthen Contracting Strategy
Seek protections such as specialty carve-outs, rate adjustments to offset administrative burden, and joint directory validation provisions.

4. Monitor Implementation
Track policy rollout and any similar actions by other insurers starting January 1, 2026.

5. Communicate with Patients
Explain potential referral impacts and encourage patient participation in advocacy efforts.

Anthem’s policy marks a significant shift in payer oversight and could reshape referral relationships across facilities and specialty groups. LUGPA will continue advocating for fair, practical policies that protect independent urology practices and preserve patient access to high-quality care.