Effective January 1, 2026, Anthem will implement a new in Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio and Wisconsin that targets the use of non-participating (out-of-network) physicians in facility-based settings. Under this policy, facilities may face a 10% administrative penalty on the allowed amount of a claim when an out-of-network provider is involved, and with repeated use, risk potential network termination.
For gastroenterology, the implications are especially concerning at the facility level, where GI procedures almost always require the support of ancillary providers such as anesthesiology, pathology, and radiology. Unlike the GI physician, who may be in-network and contracted with Anthem, these ancillary services may be delivered by groups or individuals outside of the facility’s or practice’s direct contracting control. For example:
- Anesthesiology: Most colonoscopy and endoscopy procedures require anesthesia services. If the anesthesia group contracted by the facility is out-of-network, the GI practice and the facility could be penalized despite no role in the anesthesiology group’s payer contracts.
- Pathology: Biopsies collected during GI procedures are typically sent to pathology for analysis. If the pathology group servicing the hospital or ASC is not fully contracted, the claim penalty could apply.
- Radiology/Imaging: Complex GI cases often rely on fluoroscopy, ultrasound, or advanced imaging performed by radiologists. Again, if the radiology group is out-of-network, the penalty would be triggered.
The policy shifts financial and operational risk to facilities by forcing them to police ancillary provider networks—even though GI physicians often can’t control which anesthesia, pathology, or radiology groups a facility contracts—reducing flexibility, complicating scheduling and potentially narrowing access to timely GI care. It will initially affect 11 states on January 1, 2026; we’ll monitor for expansion. If you practice in an impacted state, assess vulnerabilities now, engage facility leadership and contact ¶¶Òô´ó¹Ï for support.