Medicare Payment Final Rule Deepens Instability
CMS finalized the CY 2026 Medicare Physician Fee Schedule (MPFS), continuing the trend of payment volatility for physician services. While the One Big Beautiful Bill Act provided a modest increase for 2026, neurosurgery and other procedural specialties remain disproportionately affected by the new “efficiency adjustment” and practice expense (PE) methodology changes. Both changes are intended to increase reimbursement for evaluation and management (E/M) services.
The “efficiency adjustment” mandates a broad-based reduction in work relative value units (RVUs) and intraservice times for nearly all non-time-based services — based on the assumption that physicians deliver care more quickly as they gain experience. In 2026, this policy triggers a 2.5% cut to work RVUs, with further reductions scheduled every three years, indefinitely. Physician contracts may be based on work or total RVUs. Reductions in these values decrease reimbursement despite no reductions in work under this policy. This policy also further devalues global codes, which were already excluded from previous inflationary adjustments applied to E/M services in 2021 and 2023.
The Coding and Reimbursement Subcommittee, chaired by G. Edward Vates, MD, is actively pushing back on this policy, raising concerns over its flawed assumptions and negative downstream effects. Alongside a broad coalition, the Washington Committee urged Congress to intervene, highlighting peer-reviewed data showing operative times have remained mainly flat or increased since 2019, particularly in high-acuity surgical fields. Legislation to halt this policy is expected to be introduced in early 2026.
Similarly, the new PE methodology sharply reduces the indirect cost allocation for facility-based services. CMS justified the shift citing rising physician employment and the assumption that hospitals absorb more overhead. In response, the Washington Committee joined fellow stakeholders in calling on Congress to halt this indiscriminate PE cut. The Washington Committee and other surgical organizations proposed constructive alternatives that would have enabled a more data-driven approach to address CMS’s concerns and are currently under review by bipartisan lawmakers. Among the proposals include the creation of an employed physician modifier combined with either a PE RVU adjustment factor or a third PE RVU component.
However, in a welcome development, the Washington Committee secured a key win in the final rule. CMS reversed its proposal to inappropriately reduce the value of CPT code 61624 (transcatheter permanent occlusion or embolization in the central nervous system). Following targeted advocacy by subcommittee Chair-Elect Clemens M. Schirmer, MD, PhD, CMS reinstated the RUC-recommended value of 20.00 work RVUs, acknowledging the immense skill and risk associated with these life-saving procedures. This success underscores the importance of CNS’s and AANS’s participation in the RUC process to ensure that the intensity and complexity of neurosurgical work are accurately reflected in federal payment policy.
CMS Finalizes OPPS Rule, Preserves Key Neurosurgical Codes
The CY 2026 Hospital Outpatient Prospective Payment System (OPPS) rule adopted several neurosurgery-backed changes to preserve reimbursement for essential services. Notably, CMS reversed its proposal to delete CPT codes 61624 and 61626 from the Comprehensive- APC, protecting payment integrity for endovascular treatment of CNS vascular malformations.
CMS also finalized a three-year phase-out of the Medicare Inpatient Only list, starting in 2026 with 271 services, including certain complex spine procedures such as posterior lumbar interbody fusions. The Washington Committee opposed it, citing increased administrative burden, higher out-of-pocket costs, and threats to patient safety and access to appropriate inpatient care.
New Blog Series Highlights Prior Authorization Challenges
Neurosurgery Blog launched a new series exploring how prior authorization (PA) policies harm patients and practices. Krystal Tomei, MD, a CNS Appointee to the Washington Committee, debuted the series, sharing a powerful perspective on how a well-intended system has become a costly obstacle. Upcoming posts will highlight ongoing advocacy efforts and first-hand experiences across the country.
Mounting Pressure Prompts Revisions to CMMI’s WISeR Model
Since the Fall issue of Congress Quarterly spotlighted the Wasteful and Inappropriate Service Reduction (WISeR) Model, federal scrutiny and stakeholder advocacy over the Centers for Medicare & Medicaid Innovation’s (CMMI) proposal escalated.
The six-year demonstration applies PA in traditional Medicare through third-party vendor review of select “low-value” services, including spinal procedures, neurostimulator implants, and pain management interventions.
In September, bipartisan concern over algorithmic and AI-driven PA surfaced during an Energy & Commerce hearing, with many lawmakers raising alarms about WISeR and misuse of PA in Medicare Advantage (MA). Following, Reps. Lois Frankel (D-FL) and Andy Harris, MD (R-MD) led an amendment to block WISeR implementation – one of the few to win full committee support in the FY 2026 health spending bill. The legislation awaits Congressional passage.
In response, CMMI announced several updates in October. Deep brain stimulation (DBS) for Parkinson’s disease was removed from the targeted services list. CMMI also committed to improving transparency around clinical guidelines, developing a “gold card” program to reward appropriate use, and selecting vendors with both provider and payer clients — avoiding insurer-owned entities.
Congress and the Washington Committee responded with further action. On November 7, Reps. Suzan DelBene (D-WA) and others introduced the Seniors Deserve SMARTER Care Act (H.R. 5940) to repeal the WISeR, with companion legislation introduced by Sen. Patty Murray (D-WA). Rep. Greg Landsman (D-OH) followed with the Ban AI Denials in Medicare Act (H.R. 6361), which would prohibit Medicare pilots from using AI-based PA. The Washington Committee led a coalition letter thanking appropriators for supporting the amendment and outlining six reforms to improve transparency and accountability. The Washington Committee also submitted a follow-up letter to CMMI pressing for a meeting to discuss operational fixes.
On December 27, CMMI responded again with several revisions in its operations guide. Most notably, percutaneous image-guided lumbar decompression was delayed, and spinal arthrodesis (i.e., CPT 22585) was removed from the list. CMMI also revised its associated codes list and documentation requirements, warranting further review by surgical specialties. CMMI clarified that while only the facility claim is subject to prior authorization under WISeR, associated professional claims will not be automatically denied or held. However, physicians may face post-payment clawbacks if the facility claim is denied. This also raises questions about how this structure could affect physician eligibility for gold-carding.
As of early January, the revised program is moving forward. CMMI is also committed to launching participant electronic portals in early January, with a 72-hour turnaround time for requests sent to vendors for dates of service on or after January 15. Participants who fail to meet this may face payment penalties or other corrective actions.
In related news, the Improving Seniors’ Timely Access to Care Act (H.R. 3514/S. 1816), which would modernize and increase accountability for the use of PA in MA, closed out 2025 with 243 House and 65 Senate cosponsors. This progress reflects the efforts of the Regulatory Relief Coalition (RRC), of which the Washington Committee is a founding member. Highlights of the RRC’s work are available here.
Synergy at AMA House of Delegates
At the AMA House of Delegates (HOD) Interim Meeting, the Neurosurgery Delegation, chaired by Joshua Rosenow, MD, drove coordinated advocacy across a wide range of policy issues. The delegation tracked over 70 resolutions, submitted 32 online testimonies, coauthored resolutions, and secured key amendments supporting the Washington Committee’s regulatory and legislative priorities.
In a high-profile win, the delegation’s co-led resolution opposing Elevance Health’s proposal to penalize facilities that use out-of-network clinicians was adopted with broad support. The policy, which would undermine key protections of the No Surprises Act, drew national media attention, including comments from AANS Alternate Delegate Brian Gantwerker, MD, in Becker’s Spine Review. Prompted by the resolution, the AMA led national engagement with the AANS and CNS joining.
The delegation also played a central role in defeating a resolution that sought to direct the AMA to oppose the WISeR Model. Neurosurgery helped lead a coalition of specialty societies urging referral of the resolution, citing concerns that it would jeopardize ongoing physician-led negotiations with CMMI, which the Washington Committee is spearheading. The Specialty and Service Society Caucus overwhelmingly sided with Neurosurgery’s position.
Finally, the delegation partnered with other surgical specialties to shape AMA policy on prior authorization, clinical quality, health data infrastructure, and AI oversight. Anthony DiGiorgio, MD, a Washington Committee member and delegate of another organization, collaborated with the neurosurgery delegation on strategy and testimony.
New Study Confirms Repealing Liability Caps Raises Costs
A new peer-reviewed study published in Health Economics confirms that repealing limits on non-economic damages significantly raises medical liability premiums, especially in high-risk specialties.
Conducted by researchers from RAND Corporation, Brown University, and Harvard Medical School, the study analyzed the aftermath of court decisions in Georgia and Illinois that invalidated longstanding damage caps. Following these rulings, liability premiums increased by 20–23%.
The Health Coalition on Liability and Access, of which the AANS and CNS are members, issued a press release applauding the study, which substantiates what physicians and patients have long known and reinforces the need to preserve balanced tort reforms.