Independent physician practices are essential to patients in communities nationwide. But a new proposal from the Centers for Medicare & Medicaid Services (CMS) could make it significantly harder for some of these practices to remain viable.
That’s why the American Medical Association is urging CMS to reject a proposal that would cut Medicare payment by 50% when a physician provides a separately identifiable office or outpatient evaluation and management (E/M) visit on the same day as most procedures are performed.
CMS has not provided the evidence needed to justify a cut this large. And for independent physician practices already working to keep up with rising costs, the consequences could be severe.
Revision without reasons
Physicians know that a patient may come to the office with a new or worsening problem that requires evaluation, diagnosis and medical decision-making—and also need a procedure during that same visit. When those services are distinct, physicians should be paid for both. Physicians appropriately report Modifier -25 to indicate that an E/M service is significant and separately identifiable from the procedure.
The AMA is also pressing CMS to explain why it is reviving this policy now. The agency considered a similar, narrower proposal in 2019 and ultimately chose not to finalize it after reviewing feedback from physicians and other stakeholders. The current proposal is broader, extending the policy to more procedures. What has changed? CMS should provide the evidence supporting this significant expansion.
Medicare already has a process for addressing genuine overlap in payment. The AMA and medical specialty societies work through the AMA/Specialty Society Relative Value Scale Update Committee (RUC), alongside CMS, to review the resources required to provide medical services. That process already accounts for work that overlaps when procedures are commonly performed with an E/M service.
If specific services still contain duplicative resources, those services should be identified and reviewed individually. The AMA believes CMS should use that established process—not impose a blanket 50% reduction that will severely impact payment for individual services and the physicians needed to perform them.
The consequences could be especially profound for independent, office-based practices, which bear the costs of clinical staff, supplies and equipment needed to provide care. For some services, CMS’s own example shows that the proposed reduction could leave payment below these direct costs, even before accounting for the physician’s role.
Ensuring patient access
That is not a sustainable payment system. And it runs counter to the goal of maintaining strong independent practices and ensuring patients—particularly those in rural and underserved communities—continue to have access to care.
The AMA will continue advocating for CMS to withdraw this proposal and work with physicians and other stakeholders to address any genuine instances of duplicative payment through targeted, evidence-based changes.
To keep practices open, physicians should be paid fairly for the care they provide. Patients benefit when physicians can keep their practices open, sustainable and focused on providing care. Medicare policy should support that goal—not make it harder to achieve.
Private practice physicians already are under tremendous pressure trying to keep their practices open. How does it make any sense to pay a physician less for doing what is right for their patients?
