From facility penalties to time caps, anesthesiologists have spent the last two years absorbing insurer workarounds aimed, directly or indirectly, at paying less for anesthesia care.
According to the American Society of Anesthesiologists, the pattern is not a coincidence but a strategy, and it has put itself at the center of the pushback.
“Big insurance companies have used increasingly aggressive, profit-driven behaviors to harm frontline physicians and healthcare professionals,” the ASA said in a policy brief shared with members.
The group argues insurers have “leveraged their stranglehold on state-level insurance markets to slash payments to frontline healthcare professionals, often without regard to patient or clinical needs,” and that anesthesiology groups, which often lack the leverage of larger specialties, are especially exposed when a payer unilaterally rewrites the rules mid-contract.
Here are five insurer tactics the ASA said it is fighting, and what has happened with each so far:
1. Facility penalties tied to out-of-network anesthesiologists
Anthem Blue Cross Blue Shield plans have rolled out a policy that docks a hospital’s facility payment by 10%, 7.5% in some states, anytime an out-of-network provider, including an anesthesiologist, is involved in a patient’s care. The policy is aimed at hospitals, but the ASA and other specialty societies say it effectively pressures hospitals to force independent anesthesiology, radiology and emergency medicine practices into Anthem’s network on the insurer’s terms, since hospitals have little control over which physician groups individually contract with which payers.
The policy took effect Jan. 1 in 11 states, and a bipartisan group of lawmakers, including members of both the House GOP Doctors Caucus and the House Democrat Doctors Caucus, asked federal regulators in December to investigate it.
The ASA applauded the congressional request, saying it “reflects a shared commitment to safeguarding patient access to high-quality hospital-based care.” Indiana has since banned the practice outright through legislation, while the policy remains in place in more than a dozen other states where Anthem operates, and hospitals in several states have sued over it.
2. Capping how much anesthesia time insurers will pay for
In November 2024, Anthem told providers in Connecticut, New York and Missouri it would reimburse anesthesia care only up to a predetermined time limit per procedure, regardless of how long the surgery or the patient’s recovery actually took. The ASA warned the policy would “arbitrarily pre-determine the time allowed for anesthesia care” and penalize anesthesiologists for complications, longer operations or sicker patients that are entirely outside their control. The proposal set off a public backlash, amplified on social media and criticized by New York Gov. Kathy Hochul, that led Anthem to fully reverse the policy, with the insurer calling the reversal necessary due to “widespread misinformation” about the plan. Even so, the ASA has said it “remains vigilant” against similar time-based limits resurfacing elsewhere.
3. Quietly dropping extra payment for sicker patients
Anesthesia billing has long included physical status modifiers — codes that reflect how medically complex a patient is, from a healthy patient (P1) to someone with a severe, life-threatening condition (P5). Several major insurers have stopped paying the extra amount tied to the higher-acuity modifiers.
Aetna eliminated additional reimbursement for modifiers P3 through P5 on Medicare Advantage claims in April 2024 and extended the change to commercial plans that July, joining Blue Cross Blue Shield plans in Illinois, New Mexico, Oklahoma, Texas and Montana that had made similar moves.
Then-ASA President Ronald Harter, MD, said the modifiers “reflect the challenges associated with providing anesthesia services to patients with the greatest severity of medical conditions,” and that removing them would mean “BCBS and Aetna are moving away from patient-centered care, placing profits over patients.”
4. Halting payment for qualifying circumstances
Anesthesia coding also accounts for “qualifying circumstances” — add-on codes for situations that make a case inherently riskier, such as patients younger than 1 or older than 70, emergencies, or cases involving extreme hypotension or controlled hypothermia. UnitedHealthcare eliminated reimbursement for both physical status modifiers and qualifying circumstances in a policy announced in July 2025 and effective Oct. 1, 2025. Then-ASA President Donald Arnold, MD, called the move a break from “a meaningful standard in healthcare — that patient care be individualized,” adding that “insurers disregarding the needs of medically complex patients flies in the face of basic healthcare” and accusing UnitedHealthcare of padding its profits at the expense of payments for those providing important care to complicated patients.
5. Slow-walking payments won under the No Surprises Act
Anesthesiologists frequently end up out of network involuntarily, and a hospital may be in network while an anesthesiology group is not, which puts many of their claims through the No Surprises Act’s independent dispute resolution process. Anesthesia groups win 83% to 88% of those cases, but the ASA and providers say insurers are gaming the law’s own payment deadline: The No Surprises Act requires payment within 30 days of a losing arbitration decision. However, insurers routinely take 90 to 120 days to pay even after losing, with little practical recourse for providers since a recent court ruling found the law does not grant a private right to sue over unpaid arbitration awards. A proposed No Surprises Enforcement Act would impose financial penalties, three times the disputed payment difference, plus interest, on insurers that miss the deadline.
The ASA argues the fix should be straightforward: “Making timely payments to anesthesia groups who win the arbitration shouldn’t be up for debate.”
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