Anthem to dock NY facilities 7.5% of the claim for out-of-network care, starting July 1

Anthem will dock New York participating facilities 7.5% of the allowed amount of any claim that involves an out-of-network provider, under a Facility Administrative Policy posted to its New York provider news site. The bulletin states Anthem “will implement the following policy effective July 1, 2026.”

The penalty language is specific. Participating facilities that have nonparticipating care providers rendering services to Anthem members in an inpatient or outpatient facility-based setting “may be subject to” two 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.” Facilities may not balance bill members for the reduction.

That base matters for ambulatory surgery centers. The hit lands on the facility’s claim, not on the out-of-network clinician’s payment — so an ASC that uses an out-of-network anesthesiologist, radiologist, or pathologist for one component of a case absorbs the cut on the whole facility claim. The bulletin carves out emergencies, cases with Anthem prior approval, instances where no participating provider is available in the same geographic area, and rural, critical-access, and safety-net hospitals.

Providers are contesting the rollout. In an amNewYork op-ed, Harris Beach Murtha attorneys Roy W. Breitenbach and Peter M. Hoffman write that the policy is “coming to New York in July” and frame it as a response to the federal No Surprises Act arbitration system, where out-of-network providers win most disputes. They characterize Anthem’s threatened penalty as “7.5 percent to 10 percent of the additional IDR determination” — a provider-side reading that differs from the bulletin’s “allowed amount of the facility’s claim” base — and note “there has already been a lawsuit challenging the Anthem IDR policy in California.”

The mechanic gives New York ASCs a concrete number to plan around: every Anthem case touched by an out-of-network provider, outside the exceptions, costs 7.5% of the facility claim once the policy takes effect July 1.