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Anthem issued a new facility policy on January 1, 2026. It creates billing risk for ASCs with out-of-network providers in their case mix. For ASC billing teams, this is a live issue. 

What the Policy Does

Anthem applies a 10% administrative penalty to claims associated with out-of-network (OON) providers used in cases covered under an Anthem plan. 

 For a busy ASC with many OON cases per billing period, that cut adds up fast. Anthem can also drop a facility from its network for repeat issues. That creates a long-term contract risk on top of the direct claim loss. 

This policy has drawn pushback from the AMA and over 90 other medical groups. They argue it conflicts with the federal No Surprises Act. That dispute is still open. The policy is active for all 2026 service dates. Full details are still being confirmed and plan rules may vary. Get the current policy from Anthem provider relations before acting on it. 

Where the Billing Risk Builds

The gap between case booking and billing is where risk grows. A case is set up weeks ahead. By the time it is done, a provider’s network status may have changed. If your team does not catch that shift before the case date, the claim is at risk.

This is a timing problem, not a coding problem. A check at booking does not hold at the time of service. That gap is where this policy hits the ASC’s bottom line.

Three Things to Do This Week

Do not wait for a denied claim to find your exposure. By the time a claim comes back short, the case is done and your options are few. The time to act is before the case is performed – not after it is billed.

Start by pulling your OON Anthem case list. Go through every booked case where a provider may be out of network on an Anthem plan. This does not have to be a full audit. You are looking for active exposure in your near-term schedule – cases that have not been performed yet and still have time for review.

Once you have that list, get the full policy text from Anthem provider relations. Do not rely on third-party summaries, including this article, for final decisions. The policy language that governs your specific plan types needs to come directly from Anthem. That document is what your billing and legal teams need to work from.

Then flag every upcoming Anthem case that carries OON risk before it reaches the procedure room. The review must happen at booking, not at claim time. A flag at scheduling gives your team a window to correct the issue or document the case properly. A flag after the claim is filed gives you a dispute process and a wait.

How Revenue Cycle Management Software Can Help

Most ASC billing teams check insurance at intake and do not re-check before a case is done. That leaves provider network status unknown at the point of care.

CERTIFY Pay flags OON status at booking so billing teams can act before the case reaches the procedure room. When an OON flag is raised at booking, billing teams have time to act before a case results in a denied or cut claim. That early flag cuts the cleanup work that Anthem’s new policy would add.

ASCs with large payer mixes need revenue cycle management tools that surface these issues early. Catching a network status problem at booking takes minutes. Fixing it after a claim is filed takes weeks.

What Is Still Not Clear

How Anthem will apply this policy across all plan types is not yet confirmed. Enforcement details, plan-specific exclusions, and appeal steps are still coming out. More clarity will follow – but waiting for it is not a safe billing position.

What is confirmed is that the 10% cut is active for 2026 service dates. The risk is live now. Act on what you know today. Pull your OON Anthem case list, get the policy text from provider relations, and review how your team checks network status before a case is performed.

If your booking workflow does not include a network status check close to the date of service, that is the gap to close first. CERTIFY Pay supports OON verification workflows that flag exposure at scheduling, before a case reaches the procedure room. Talk to our team about OON verification workflows for your ASC.