Intensifying payer oversight of anesthesia reimbursement is spurring hospitals and anesthesia groups to examine closely which procedures receive anesthesia support.
“Payer pressure is forcing much tighter scrutiny of which cases get anesthesia support,” Megan Friedman, DO, chair and medical director at Los Angeles-based Pacific Coast Anesthesia Consultants, told Becker’s.
That scrutiny, in turn, is changing how hospitals, health systems and anesthesia groups plan staffing, schedule cases and determine which procedures receive continuous anesthesia presence.
One of the most visible manifestations has been payer efforts to impose time limits on anesthesia reimbursement. In late 2024, Anthem Blue Cross Blue Shield proposed a policy that would impose time limits on anesthesia reimbursement in Missouri, New York and Connecticut. The proposal drew intense backlash from clinicians and lawmakers, prompting Anthem to reverse course. Anthem attributed the reversal to what it described as “widespread misinformation” about the update.
A month later, Kaiser Foundation Health Plan also reversed an anesthesia reimbursement change it had implemented in Washington state. At the same time, several states — including Illinois, New York and Washington — introduced or advanced legislation aimed at banning similar cuts.
Despite reversals and backlash, some payers moved ahead with changes. Anthem rolled out a policy revision effective Feb. 1, 2025, affecting commercial plans in Connecticut, New York and Missouri. Under the policy, Anthem will calculate allowable anesthesia time based on CMS physician work time values rather than the actual documented anesthesia time. The change applies to anesthesia claims billed under CPT codes 00100 through 01999 and could result in claim denials when procedures exceed preset time thresholds.
“I think the Anthem decision to reimburse on CMS average minutes rather than actual minutes will further deteriorate anesthesia reimbursement, leading to further pressure on hospitals and ASCs to make up the difference, more anesthesiologists leaving medicine and further reductions in access to care,” David Vierra, MD, an anesthesiologist with Providence Medical Group-Napa (Calif.), told Becker’s in 2024.
Time-based policies are only one part of what anesthesia leaders describe as intensifying payer oversight. Dr. Friedman said that her team is seeing more denials for anesthesia in routine GI cases, increased scrutiny of monitored anesthesia care versus general anesthesia and more rigid definitions of medical necessity.
Those trends are pushing organizations to reassess “blanket coverage” approaches that historically kept anesthesia teams continuously present across procedural areas.
“As a result, hospitals and anesthesia groups are rethinking blanket coverage models,” Dr. Friedman said. “Historically, anesthesia groups absorbed inefficiencies, which is why many have shifted to hourly models.”
In response, some systems are moving toward tiered coverage models, “reserving continuous anesthesia presence for higher-acuity, higher-risk cases and shifting lower-acuity cases to consult-based or demand-based support,” she said.
At her team’s facilities, anesthesia leadership is becoming more involved upstream.
“Decisions about which cases require anesthesia support are made in real time by anesthesia leadership rather than solely by schedulers or payer rules,” she said. “That ensures patient safety remains the primary driver.”
Still, she emphasized that reimbursement policy often doesn’t match clinical reality, especially outside the OR. The challenge is that many non-operating room anesthesia cases still require anesthesia involvement regardless of reimbursement, she said. Until reimbursement reflects that reality, facilities will absorb those costs.
While many conversations about anesthesia hammer workforce shortages, Dr. Friedman said the strain can persist even within fully staffed groups.
“Our group is fortunate right now that we’re fully staffed,” she said. “But one thing that we see — even as facilities are staffed — is a temporal and site-level mismatch.”
She said procedural demand has become more volatile and front-loaded across GI, cath lab and other NORA locations.
“Anesthesia staffing models are still built around six daily blocks and historical averages, but we see consistent surges early in the day and then late add-ons and short-notice case stacking that outstrip scheduled anesthesia coverage,” she said. “That’s followed by midday lulls where providers are staffed but underutilized.”
As more advanced procedures move into catheterization labs, hybrid rooms and IR suites, she expects the mismatch, and the consequent costs, to accelerate.
