Elevance Health, the insurer behind Anthem plans, said Sept. 29 that it will stop paying hospital rates for certain care delivered at hospital-owned clinics located away from the main hospital campus. According to the company's announcement of new billing transparency policies, those services will instead be paid at the lower off-campus rate. The policies will roll out during 2026 and 2027 across its commercial, Medicare Advantage, and Medicaid plans.
The change targets a billing practice that surprises many families. When a hospital system buys a neighborhood doctor's office, the same visit with the same doctor can be billed as hospital outpatient care, often with an added facility fee. Elevance, whose companies serve about 104 million people, said one member's bill rose to more than 10 times the normal amount because of this kind of billing.
For households, the concern is practical. Higher payments flow into deductibles, coinsurance, and premiums, so a routine visit, lab test, or imaging scan can cost more depending on who owns the building rather than what care was provided.
Same Doctor, Same Visit, Higher Bill
Site-of-care billing refers to paying a claim based on where care happens. Medicare and many commercial plans have long paid more for services in a hospital outpatient department than in an independent physician's office. Hospitals say facility fees help pay for round-the-clock staffing, equipment, and stricter regulatory standards.
The problem arises when a clinic miles from the hospital is registered as a hospital department. Patients may receive two bills, one from the physician and one for the facility, even though the office looks and works like any other practice. Claims have not always shown clearly where care actually took place.
The costs add up nationally. Elevance cited a 2023 Blue Cross Blue Shield Association analysis finding that, for four common services, Medicare paid an additional $2.7 billion and patients paid $411 million more out of pocket over three years when the services were delivered in hospital outpatient settings instead of physician offices. Federal health spending data show hospital care reached about $1.6 trillion in 2024, roughly 31% of U.S. health spending.
Inside Elevance's New Billing Rules
Under the new policies, hospitals must identify the physical location where care was provided. Elevance will check billing information against hospital addresses, pay certain off-campus services at the off-campus rate, and block higher hospital billing for some lab tests performed elsewhere. The company says it is the first commercial insurer to announce that it will require location on billing forms.
Elevance announced the policies at the Make America Healthy Again (MAHA) Summit in Washington. "These changes will give us better information to help us pay accurately and support our work to make health care more affordable," said Dr. Catherine Gaffigan, president of health solutions at Elevance. "Increasingly, our customers demand affordability, and we have a responsibility to deliver that to them," she said, adding that the actions will help the company address wasteful spending and manage premiums.
The move follows state and federal action. Elevance noted that Indiana and Maine have strengthened billing requirements for off-campus care. Separately, a provision in a bipartisan spending law Congress passed earlier this year will require off-campus hospital departments to bill under their own unique National Provider Identifier numbers starting in 2028, Fierce Healthcare reported.
States are also enforcing disclosure rules. On Sept. 25, Maryland Attorney General Anthony G. Brown announced that the University of Maryland Medical System would pay $2,251,781.52 in restitution to certain patients who paid out-of-pocket facility fees at some of its hospital clinics before the state's Facility Fee Right-to-Know Act took effect on July 1, 2021. The health system denied that patients had been inadequately informed but agreed to the settlement. Eligible patients should receive refund checks over the next six months.
Savings Could Be Modest, and Key Details Are Missing
Independent analysts welcomed the direction but cautioned against expecting large savings. Loren Adler, a fellow and associate director of the Brookings Institution's Center on Health Policy, told Axios that the policy should lower prices, but "the magnitude is unlikely to be terribly large." He also said he did not have a good sense of why insurers had not acted sooner.
Important questions remain unanswered. Elevance's announcement does not list which services are affected, which states or plans will see changes first, exact start dates, or how much member cost sharing will fall. It also does not say whether hospitals will be barred from billing patients separately for facility fees that Elevance declines to pay at hospital rates.
Hospital groups have long defended facility fees as necessary to support hospital infrastructure, so lower payments could become a point of tension in contract negotiations.
Protecting Yourself From Surprise Facility Fees
People with Anthem or other Elevance plans do not need to take immediate action, since the changes phase in through 2027. Still, patients can reduce surprises now. Before a nonemergency visit, ask whether the clinic is hospital-owned and whether a separate facility fee applies.
Review each explanation of benefits for two charges on the same date, one professional and one facility. If your doctor's office was recently bought by a health system, compare your costs before and after. Ask whether lab work or imaging can be done at an independent site, which may cost less.
If a bill seems wrong, call your insurer and ask for an itemized statement. Maryland residents can contact the attorney general's Health Education and Advocacy Unit for help with billing disputes, and many states offer similar consumer help lines. Patients who struggle to pay can ask about financial assistance, which nonprofit hospitals must offer under federal tax rules.
Elevance's changes move billing toward paying for care based on where it actually happens, but how much families will save remains unclear until the company releases service lists and effective dates.
Key Questions Answered
What is Elevance changing?
It will require hospitals to report where care took place and will pay certain services at hospital-owned off-campus clinics at off-campus rates instead of higher hospital rates.
What is a facility fee?
A facility fee is a charge a hospital adds for the use of its space, staff, and equipment. It is often billed separately from the doctor's fee, even at clinics away from the main hospital.
When will members see changes?
Elevance says the policies will roll out during 2026 and 2027. It has not published specific dates by service or state.
Will my out-of-pocket costs drop?
Possibly, but Elevance has not said by how much. A Brookings health policy expert expects the overall effect on prices to be modest.
How can I avoid a surprise facility fee?
Ask before a visit whether the clinic is hospital-owned and whether a separate facility fee applies, and review each explanation of benefits.
Who is getting money back in Maryland?
Certain patients who paid out-of-pocket facility fees at some University of Maryland Medical System hospital clinics before July 1, 2021, will receive refunds under a settlement announced Sept. 25.
Published by Medicaldaily.com
