Here are three recent policy decisions by public and private insurers that are disrupting ASCs and physician practices:
1. Several physician associations are urging Elevance Health to abandon its new policy that penalizes hospitals and contracted facilities for using care providers who are not in-network with its Anthem Blue Cross Blue Shield commercial plans in 11 states. Under the policy, finalized Oct. 1 and set to take effect Jan. 1, facilities could face an administrative penalty equal to 10% of the allowed amount of any facility claim involving a nonparticipating provider. Facilities are prohibited from passing this penalty on to patients, and they risk termination from Anthem’s network if they repeatedly use out-of-network care providers.
2. In its finalized 2025 physician fee schedule, CMS included an ‘efficiency adjustment’ of negative 2.5% work relative value units, sparking an outcry among physicians. Dozens of physician organizations condemned the rule and the reduction, with the American Medical Association arguing that reimbursement under Medicare will shrink for more than 7,000 physician services. This represents 95% of all services provided by physicians, according to the AMA, which has advocated for an alternative payment structure.
3. CMS is advancing a major step toward site-neutral payment reform in its proposed 2026 Hospital Outpatient Prospective Payment System rule, a move that could redefine how hospitals and ASCs collaborate. The proposal, which closed for public comment Sept. 15, aims to reduce long-standing disparities in Medicare reimbursement between hospitals and physician offices. CMS estimates that hospitals currently receive about 60% higher payments than physician offices for similar services due to differences in how professional and facility fees are calculated.
“Site-neutral payments are a focus for President Donald Trump’s administration and the current Congress,” said Adam Bruggeman, MD, CEO of Texas Spine Center and chair of the AAOS Advocacy Council, during a keynote at Becker’s 22nd Annual Spine, Orthopedic, and Pain Management-Driven ASC + The Future of Spine Conference in June. “I’ve met with senators who are shaping these policies, and the goal is not to bring up surgery center payments — it’s to bring hospital payments down to surgery center levels,” Dr. Bruggeman said. “That’s going to reshape purchasing, supply chain leverage and how vendors respond when everyone gets paid the same.”
