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Starting January 1, 2026, Elevance Health will consider “corrective measures” that penalize healthcare facilities in 11 states for using out-of-network providers to deliver care for the large insurer’s Anthem Blue Cross Blue Shield commercial health plan members. Health systems may be subject to an administrative penalty of 10% of the allowed claim amount and potential network termination, and the penalty cost cannot be passed on to the patient, according to an Anthem memo. Emergency care and any care that is preapproved for an out-of-network provider are exempt, but otherwise, all providers of all components of a member’s care must be under contract.
What to do: For urgent care centers that might be in the throes of negotiating clinical staff turnover and credentialing lags, the Elevance policy has financial implications. The bottom line is that urgent care centers must accelerate their credentialing process to ensure all practicing providers are in-network or risk substantial revenue loss and possible loss of network status.
- Financial penalties: If a new provider sees patients before their credentialing is finalized, the urgent care facility will be assessed the 10% administrative penalty on commercial claims involving that provider, who essentially is out-of-network until the credentialing is complete.
- Increased exposure: High turnover means an urgent care center could frequently have new, uncredentialed staff with greater risk of penalties.
- Risk of termination: Persistent credentialing issues could lead to eventual termination from the Elevance provider network.