| Doctors are mobilizing against a small provision in a sprawling Medicare payment rule that could affect how they bill when a procedure and a separate office visit happen on the same day. The Centers for Medicare and Medicaid Services wants to change the way Medicare pays for those cases starting next year. The change would apply when a doctor completes an evaluation and management visit alongside certain procedures. - For example, a patient visits a dermatologist for a suspicious mole and a new rash. During the visit, the doctor evaluates the rash and also biopsies a separate suspicious mole. Under current rules, the doctor can bill for both the evaluation and the biopsy when the evaluation involves significant work beyond the procedure itself.
- Under the new proposal, however, the agency would pay the higher-valued service at the full rate, then cut payment for the other service by 50 percent.
Rahul Shah, who leads the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) calls the proposal “arbitrary and capricious,” arguing the cut would hurt patient access and strain providers by not fully covering the cost of the service. “Where did you come up with 50 percent?” Shah asks rhetorically. “We’d love to see the evidence on this.” In response to the proposed payment cuts, the AAO-HNS has spearheaded the Same Day Care Coalition, which is urging the Trump administration to back off. The group represents a broad range of other medical and surgical providers, including dermatology, orthopedics, neurology and rheumatology. Doctors and lobbyists have been talking with Trump administration officials, including in meetings this week, to relay their issues with the proposal. Shah, a practicing physician who has been in some of these meetings, tells me that he feels the administration has heard the concerns from providers — but it’s still not clear what will happen before the rules must be finalized by Nov. 1, so they’re not letting up. More than 1,400 ear, nose and throat (ENT) doctors responded to a survey AAO-HNS proffered about what the cuts would mean for their practices — a response rate Shah tells me shocked him. The results were even more eye-opening: More than 80 percent said finalizing the proposal would delay care or make obtaining care more difficult, while 67 percent responded that they would need to decrease the number of Medicare patients they’re able to see. Nearly 1 in 3 said they would likely need to lay off staff due to the cuts. “Those numbers are staggering, and that’s what woke me up to say, ‘Whoa, whoa, we’re going to have a crisis,’” said Shah. Shah says he also wants to meet with “any member of Congress that will give us the time of day” to discuss the potential impacts as well. The group has organized thousands of letters to congressional offices and to CMS. Why it matters: The payment rules are complex, but they can ultimately have an impact on how commercial health insurers craft their own policies. - Earlier this year, a health plan in Michigan announced it would be implementing a similar 50 percent cut to certain same-day services before delaying the policy without a new start date. Other insurers have also taken aim at these kinds of payments.
- The American Medical Association, which is also pushing the Trump administration to withdraw the proposal, argues that the policy would harm independent physician practices in particular because they have to absorb the costs of overhead, including staff, supplies and medical equipment needed for 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,” writes Willie Underwood III, the AMA’s president, in a blog post. “That is not a sustainable payment system,” Underwood added. “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.” → Last year, the AMA said about 42 percent of doctors were in private practice in 2024, the lowest-ever amount. An analysis from Avalere Health found that fewer than 20 percent of physicians practice independently, with 82 percent of practicing doctors employed by corporate entities or larger hospitals at the beginning of 2026. Providers worry that payment cuts could lead to office closures or further consolidation — which some say could drive up cost or further reduce access to care. What’s next: Public input on the payment rule proposals is due by Sept. 15, and the rules are set to be finalized by Nov. 1. More than 16,000 people have weighed in so far. EXECUTIVE HEALTH BRIEF The provision is tucked inside Medicare’s annual physician fee schedule, the massive annual rule that sets payment rates for doctors. This year’s proposal runs about 1,600 pages, but this particular change takes up only a few. At issue for CMS: When a doctor performs a procedure and conducts a separate office visit for the same patient on the same day, CMS says some of the work involved in the two services overlaps. The agency argues that Medicare shouldn’t pay the full rate for both. While there is a process in place to adjust some of that overlap, CMS says it “tends to recommend only minor adjustments.” And, with thousands of affected billing codes, CMS says that reviewing them one by one to ensure accuracy is “not a practical solution.” Meanwhile, the AMA notes that CMS considered — and then rescinded — a similar proposal in 2019 after pushback from providers and patient advocacy groups. “The current proposal is broader, extending the policy to more procedures. What has changed? CMS should provide the evidence supporting this significant expansion,” Underwood said. In response to an inquiry pointing to the questions and concerns from providers, CMS said “the agency does not provide additional policy interpretation, discuss the rationale beyond what is described in the proposed rule, or preview potential regulatory decisions outside of the formal rulemaking process.” “As stated in the proposed rule, this proposal would align with existing, long-standing Medicare policies to reduce payment when multiple procedures are furnished on the same day for the same patient,” the CMS spokesperson said in an email. “Measles’ role in child’s death ignites fight between RFK Jr. and Pennsylvania governor,” report The Post’s Rachel Roubein, Lena H. Sun and Caitlin Gilbert. “BioNTech, Roche Scrap Cancer Vaccine Trial in Blow to New Field,” Sonja Wind and Naomi Kresge report at Bloomberg. This newsletter is published by WP Intelligence, The Washington Post’s subscription service for professionals that provides business, policy and thought leaders with actionable insights. WP Intelligence operates independently from The Washington Post newsroom. Learn more about WP Intelligence. | 
