Tag: reimbursement

A new survey from the American Academy of Otolaryngology–Head and Neck Surgery finds that a CMS proposal to cut same-day evaluation payments by 50% could drive ENTs to reduce Medicare patient capacity or exit the program altogether. More than 1,400 otolaryngologists say a proposed Medicare payment cut could reduce seniors' access to specialty care, according to new survey data released Aug. 19 by the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS). The survey, which collected 1,406 responses from AAO-HNS members between July 28 and Aug. 13, found that eight out of 10 ENTs believe the Centers for Medicare & Medicaid Services (CMS) proposal would reduce access to care for Medicare beneficiaries. More than two-thirds of respondents (67%) said they would have to see fewer Medicare patients if the policy is finalized, while 14% said they would stop accepting Medicare entirely. The Proposal: Modifier -25 and Same-Day Services At the center of the debate is CMS's proposed changes to the 2027 Medicare Physician Fee Schedule (MPFS), which would cut reimbursement for services billed under Modifier -25. Modifier -25 is used when a physician performs a separate medical evaluation and a procedure during the same patient visit. Under the proposed rule, CMS would pay the higher-cost service in full and reduce payment for the other service by 50%—a threshold the agency argues addresses potential duplicate payments. However, CMS acknowledges in the proposed rule that the current payment system already accounts for overlapping work when services are provided together, and the agency does not provide evidence showing a 50% overlap in the remaining work. For ENT physicians, the clinical implications are significant. A patient presenting with symptoms raising concern for head or neck cancer, for example, may be evaluated and undergo an in-office procedure during the same visit—avoiding additional delays, travel costs, and anxiety. Under the proposed cut, the second service performed during that appointment would be reimbursed at half rate, potentially below the actual cost of staff, supplies, and equipment required. The proposal is open for public comment through Sept. 14 and, if finalized, would take effect Jan. 1, 2027. Practice-Level Impact Survey respondents identified a range of potential responses if the policy moves forward, including taking on more commercially insured patients, reducing services or staffing, joining larger health systems, or closing practices. The AAO-HNS warns the consequences could be particularly severe in rural and underserved communities, where practices have less flexibility to absorb further Medicare cuts. "Physician practices are already being squeezed from every direction," says Rahul K. Shah, MD, MBA, AAO-HNS CEO and executive vice president, in a release. "Years of inadequate Medicare payment have made it harder to keep staff, invest in care, and maintain patient access. Now CMS is proposing to pay half for medically necessary work that physicians perform in full. At some point, the math stops working—and when that happens, every patient in the practice feels it." AAO-HNS President Eugene Brown III, MD, RPh, CEO of Charleston ENT & Allergy and its 17 locations in South Carolina, echoed those concerns. "The care does not become less important because it happens on the same day as a procedure," says Brown, in a release. "If I evaluate an older patient and find something concerning, I may be able to begin the next step in that evaluation right then. I am still doing the same careful work, making the same medical decisions, and taking the same responsibility for that patient. Paying half for that care undervalues what physicians are actually doing for our seniors." Coalition Pushes Back The AAO-HNS and nearly 20 national physician and patient organizations within the Same Day Care Coalition are urging CMS not to finalize the proposed 50% payment reduction. The coalition is calling on CMS to fully evaluate the impact on patient access, timely treatment, and physician practice sustainability before making any changes. More information on the AAO-HNS's Medicare patient access efforts and the full survey results are available at entnet.org. Featured image: A female audiologist uses an otoscope to examine a senior woman's ear. Photo: AAO-HNS

Tag: reimbursement

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