Crisis & Referral Specialist

Elevance will stop paying hospital rates for some off-campus clinic care, a shift that could trim facility fees. Published Sep 30, 2026 9:39 PM EDT By Cole Mercer 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

Strive Health expands executive team to support next phase of growth. New leaders bring deep healthcare expertise across operations, provider networks and enterprise growth Susan Ray, Chief Operating Officer; Sarah Berry, Ph.D., Chief Network & Engagement Officer; Dan Heslin, Chief Growth Officer. DENVER-(BUSINESS WIRE)-Strive Health, the national leader in value-based kidney care, today announced three additions to its executive leadership team to expand its national footprint and deepen its partnerships with payors and providers. Susan Ray has joined Strive as Chief Operating Officer (COO), Sarah Berry, Ph.D., as Chief Network & Engagement Officer (CNEO) and Dan Heslin as Chief Growth Officer (CGO). Together, they will lead three critical areas of Strive's next phase of growth: delivering its care model consistently at scale, strengthening the performance and engagement of its national provider network and expanding access to value-based kidney care through new and existing partnerships. "Scaling value-based care requires strong execution, deeply engaged provider partners and solutions that deliver value for our patients and customers," said Paul Marchetti, Strive's President. "Susan, Sarah and Dan bring proven expertise in building and leading complex healthcare organizations. Their leadership will help us continue to improve how care is delivered for people with kidney disease and comorbidities as we reach more patients nationwide." As COO, Ray will lead Strive's market operations and central services, overseeing customer relationships and the teams responsible for executing the company's care model at the point of delivery. Ray brings deep experience across value-based care, operations, client management and organizational transformation. Most recently, she served as COO of Rippl Care, where she helped build and scale a care model for individuals living with dementia. She previously held senior leadership roles at Honest Health, naviHealth, Evolent Health and Accolade. Berry will oversee the company's network of more than 6,500 provider partners as CNEO, along with engagement functions that connect patients with timely local care and Strive's clinical and social needs programs. Berry most recently served as SVP of clinical service operations at Ventricle Health, where she led the scaling and performance of its advanced heart failure cardiology network and clinical operations. Previously, she held senior network and operational leadership roles at Aetna (a CVS Health Company), Innovation Health and Evolent Health. As CGO, Heslin will lead Strive's business development strategy, strategic partnerships, marketing and market expansion, with a focus on bringing the company's population health solutions and partnerships across payors, providers and other healthcare organizations. Heslin joins Strive following an extensive career at Elevance Health, where he held leadership roles spanning enterprise growth, product strategy and business development and most recently served as president of the company's specialty business. Earlier in his career, he held roles at Roche Diagnostics and in technology strategy consulting. The appointments strengthen Strive's leadership across the full lifecycle of its value-based care model - from building new partnerships and engaging provider networks, to delivering care consistently for patients and customers nationwide. ABOUT STRIVE HEALTH Strive Health is the nation's leader in value-based kidney care and partner of choice for innovative healthcare payors and providers. Using a unique combination of technology - including AI - care interventions and seamless integration with local providers, Strive forms an integrated care delivery system that supports the entire patient journey from chronic kidney disease (CKD) to end-stage kidney disease (ESKD). To help patients, Strive partners with commercial and Medicare Advantage payors, Medicare, health systems and physicians through flexible value-based payment arrangements, including risk-based programs. Strive serves over 165,000 people with CKD and ESKD across 50 states and partners with over 6,500 providers. Strive's case management and population health programs are accredited by the National Committee for Quality Assurance (NCQA), and its technology platform, CareMultiplier(TM), is certified by HITRUST. To learn more, visit StriveHealth.com. 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