Dr. Catherine Gaffigan is the president of health solutions at Elevance Health. This opinion piece is a response to another opinion piece published by the CEO of the American Hospital Association, which focused on Anthem Blue Cross Blue Shield’s new facility administrative policy.
Recent commentary from certain hospital groups may lead you to believe that we are trying to make healthcare harder to access and more expensive through our non-participating provider facility administrative policy.
While that makes for a good headline, it couldn’t be further from the truth.
The purpose of this policy is to ensure that patients have access to care they need at a cost that families and employers can afford. The intent is not to restrict access to high quality care, but to address a payment dynamic that’s significantly increasing healthcare costs.
Our policy discourages in-network hospitals and facilities from using out-of-network doctors and clinicians, specifically when a patient is scheduled ahead of time for a non-emergency procedure at an in-network hospital or facility.
Congress passed the No Surprises Act to protect patients from unexpected, “surprise” medical bills. But the law is being exploited by some care providers — some backed by private equity and venture capital firms — to maximize profit at the expense of employers and patients.
The No Surprises Act created a third-party arbitration approach called the Independent Dispute Resolution process to resolve payment disputes between out-of-network care providers and the health insurers who represent patients and employers. Each side submits a proposed payment amount, and the arbitrator must choose one offer — no negotiation.
The statistics related to IDR are concerning:
- More than 850,000 IDR disputes were filed in the second half of 2024. That’s about 100 times the government’s initial projection.
- The CMS reported that in the first half of 2025, roughly 88% of IDR decisions sided with providers – with our data showing some IDR entities selecting provider offers over 98% of the time.
- For a routine hammertoe procedure, Medicare pays roughly $450 and employer-based insurance pays about $600. Through the IDR process, this routine procedure is resulting in average awards of $20,000.
- A recent national survey of health plans conducted by AHIP and the Blue Cross Blue Shield Association found that nearly 40% of disputes submitted to IDR in 2024 were identified as ineligible under the rules Congress established. Yet many of these cases still moved through arbitration instead of being screened out.
The American Hospital Association suggests that health insurance providers need to engage more fully in the IDR process or just make higher payment offers. We are fully engaged, and we have made significant investments in technology and staffing to support the IDR process.
The IDR process has been transformed into a powerful revenue generation tool that discourages in-network participation, interferes with market dynamics and drives up costs for employers and families. This is evident by the industry that has sprung up around regularly exploiting this pricey loophole — companies like the ironically named HaloMD, according to an investigation by STAT News.
While we continue to advocate for changes and improvements to the IDR process with Congress and CMS, we are taking action to protect our customers from this abusive behavior that is driving up out-of-pocket costs and health insurance premiums. As these practices become more widespread, policymakers are beginning to take notice and explore ways to restore balance to the system.
In Indiana, new legislation has been signed to identify the reasons for repeated disputes and encourage practical solutions. When disputes enter the federal IDR process at high volumes — 25 or more qualified disputes within a 90-day period — the law allows health insurers to provide written notice to all parties to initiate a structured good faith conversation with the health insurer, the out-of-network provider and the hospital or facility where services were delivered to a patient. The parties must review the pattern of disputes, examine the qualified payment amount and document the discussion in a written memo filed with the Department of Insurance, which will be published annually, identifying the number of conversations conducted and number of disputes reviewed.
Our policy is not about penalties or mandates — it’s about asking hospitals to be part of the solution. It excludes critical access hospitals, designated rural facilities, safety net hospitals, emergency services, when a patient has a prior authorization for out-of-network services, and when an in-network provider of the same specialty is not available within the geographic area.
We know families are frustrated by the rising cost of healthcare. Let’s not allow a few bad actors to drive up costs. It affects every employer that sponsors health coverage and every family that pays premiums.
