Between October 5 and October 7, nine social media influencers all posted the same Medicare argument about a relatively unknown coding modifier physicians use. A content creator, a commentary account, a MAGA account that rescues animals, a radio host, an Outkick writer, a comedian, a newsletter guy, a Townhall columnist, and a RedState columnist who used to carry the nuclear football all suddenly became experts in the minutia of healthcare billing. They don’t regularly discuss Medicare and physician coding in their posts. Their posts reach hundreds of thousands to millions of followers depending on the account. One was labeled “paid partnership”. Modifier 25 is not a scam. It’s not a loophole. It’s not some get rich scheme. Modifier 25 allows a doctor to indicate that a second, separately payable procedure was performed at the same time as another visit. What does that mean in real terms? It means an orthopedic surgeon had you on their schedule for “knee pain”. After careful examination and discussion (the clinic visit), they recognize that you would best be served with an injection (the procedure) to help with the symptoms. They then provide the injection and attach a 25 modifier to indicate that this is a separately identifiable treatment from the visit and requires its own payment for those services. CMS wants to pay the highest-priced service in full and cut every other same-day service by 50%. It is unclear how they came up with 50% and the agency even stated that they aren’t sure there is overlap in work for the two separate codes, but stated the overlap is “likely”. I’ve been clear in my opposition and why. When a plumber comes out to your house because your water supplier sent you a note that you might have a leak and then the plumber finds that leak, do they charge you half price for fixing the leak? Our own government doesn’t even follow these rules. If you go to the post office and have two packages to send to the same address, do they charge you half price for the second box since it is going to the same address? What will happen? First, we’ve determined that 80% of the impact of the -25 modifier will be on independent, private practicing doctors. We’ve created a new tax on independent physicians, pushing them further into consolidation. When doctors become employed, costs go up dramatically leading to increased premiums and increased out of pocket costs. The other impact will be on patient care. Doctors will refuse to be paid half for the same work. They will tell patients to come back on another day for the procedure. That’s another copay. That’s another day finding help with children or loved ones. That’s reduced productivity while waiting for needed treatment. And at the end of the day, the cost to the payer and patient will end up being worse as doctors consolidate.

We need to have a conversation about how uneven the changes have been to physician payments. Everyone agrees… primary care needs to be paid more. Haven’t heard anyone debate that. But how our government has decided to get that money has been a crime. It has consistently unequally hurt private, independent physicians over employed physicians and is ironically increasing the cost of care while trying to decrease the cost of care. Here are the receipts: 1) 25 modifier changes (proposed) As notated below, over 80% of the impact is on independent physicians 2) Conversion factor failing to keep up with inflation Employed doctors aren’t paid through the conversion factor while private practice doctors are. Lowering conversion factors only hurts independents. 3) modifying the Indirect Practice Expense Cost Index (proposed) Employed doctors aren’t paid through practice expense RVUs. Any modification here will only hurt independent doctors 4) indirect practice expense 50% reduction (implemented last year) Same as (3) above This is before we talk about lack of movement on physician ownership of hospitals, unfair 340B policies, continuation of ambivalence towards site neutrality, and imbalanced stark laws that penalize doctors while allowing hospitals to engage in the same behavior. I don’t think the administration is trying to hurt private doctors intentionally. I just don’t think that there is an understanding of how private doctors are paid vs employed physicians and the long term implications of unequally harming private practice (with the ultimate end game of mass consolidation) beckersasc.com/asc-accredita…

I don’t know the insinuation here (are we blaming hospitals/doctors? Are we saying the system is broken? Both?) The reality is that this construct has been around since the 1950s. Insurers designed deductibles to make sure that patients had skin in the game. The thought is that if patients don’t pay anything, patients will overutilize care. The concept was taken from other insurance products (like auto insurance) A wrinkle in the system that many don’t think about is that a third party, the physician or hospital delivering care, must stop their normal activity of delivering care to ask the patient for money. The physician or hospital didn’t design the plan, didn’t set the deductible/copay/coinsurance, and generally is an innocent bystander. But, the insurer makes the physician or hospital do their dirty work because the insurer AUTOMATICALLY removes the patient owed amount from the amount they pay a doctor. What does that mean? That means a part of a doctor’s paycheck requires them to ask for money from the patient they are supposed to be focused on treating, introducing frustration and distrust into the physician-patient relationship. Maybe this was a sound idea when the amount patients had to pay was small, but that’s not the case anymore. 75% of Americans have an out of pocket of at least $3,000. High deductible plans are increasing every year. Why? Because insurers have encouraged employers to continue to increase out of pocket amounts to keep insurance premiums down. Don’t want to pay that double digit premium increase next year? Just increase that deductible/copay/coinsurance and your premium will only go up a little bit. Here’s a little secret… the majority of patients never meet their deductible. Why is that important? Because that means that despite all those sky high premiums you paid, you still paid for every dollar of your own care. The average family pays (in combination with their employer) $27,000 per year but they, on average, get nothing back out of that money they spent. Today’s premiums are high, in large part, due to massive consolidation and corporate greed. Doctors got tired of telling their patients to pay them money, of tracking down prior authorizations, and all the other tricks insurers use to make sure patients pay every dollar of their care after premiums and the insurer never pays a dollar. Meanwhile both insurers and the federal government have paid doctors less to do more. Just with Medicare alone, doctors are at half of what they should be paid if they kept up with inflation since 2000. Private insurers seized on the governments reductions and similarly ratcheted down payments. Doctors have left private practice in droves into the arms of hospitals and insurers who have seen record profits as they both consolidate into national behemoths. The system is working exactly as it was designed… to give a few large organizations substantial profit margins. When doctors try to collect those amounts, they are called greedy. When they go out of network, they are called greedy. When they ask for increases in pay consistent with inflation, they are called greedy. Is it any wonder they now go to those same hospitals and insurers and ask for a salary with production based incentives now instead of openly asking for more pay in a public forum? Let’s write the real stories in the papers, not just surface stories about the symptoms of a sick healthcare system that has been invaded by insurers, hospitals, and government interests.

Let’s talk about physician payment for a minute and why that AMA graph just doesn’t feel like it tells the whole story. Here’s why… Let’s start with how the AMA calculates its graphic. They work on the specified update, which is what Congress set out to do that year… but that’s only half the story Each year, the conversion factor (CF) is recalculated by multiplying the prior year CF by the statutory update by the budget-neutrality adjustment. When you only go on the statutory update, you miss a big potential gain or loss due to budget neutrality. @anish_koka has explained why budget neutrality has doomed the physician fee schedule permanently. The AMA has provided Congress with years of bad data that ignores the massive financial trouble that budget neutrality has caused and created a far rosier picture. When you look at the AMA graph, it appears doctors have seen a 10% increase since 2000. The 2000 CF was $36.6137. The 2027 proposed CF is $32.84. That’s over 10% in the negative direction. We need truth in advertising. I begged the specialty societies and the AMA to fix their graphs. I spent 3 years asking for it. No one listened. So, I did what I had to do and I pulled the data together. Below is the work product of that venture and a graph that I think (visually) shows the much more striking reason why doctors are leaving medicine or selling their practices. The first graph looks at things from the perspective of the 2000 CF. If we just compare how much doctors and hospitals are paid, we see that physician pay via CF has declined 10.3% while hospital pay has increased 97% and inflation (MEI) has increased 71%. That seems pretty stark but I think the second graph uses the same numbers but in a more effective way. The second graph assumes that MEI is the baseline. In other words, what if doctors just got what they were paid in 2000, updated for the cost of inflation. Now we see what really has happened. Doctors are 81.3% behind inflation while hospitals are 26.8% above inflation. No wonder hospitals are buyers and doctors are sellers in this market. It’s time for truth in advertising. It’s time Congress and CMS heard the real numbers. 81% behind inflation over 25 years and even worse when compared to HOPDs. Our government created this crisis and they will need to understand the issues they created to get us out. Follow us at @IndeMedAction as we shine the light on issues critical to independent physicians.

The CY 2027 PFS comment deadline is September 14, 2026. Here are the comments I think need to be made. 1. Withdraw the same-day E/M and global 50% reduction. CMS backed down from this in 2019 under surgical coalition pressure. The clinical argument hasn’t changed. Modifier -25 E/M services represent separately identifiable encounters, not bundled efficiencies. Strengthen it this cycle with documented post-op contact data, portal messages, phone logs, after-hours calls, that demonstrates how much uncompensated work already occurs inside the global period and is not captured in CMS's 28% post-operative utilization rate. 2. Require specialty-level impact analysis of IPCI removal. CMS is eliminating a 17-year PE stabilization mechanism and replacing it with a 5% annual cap. Independent practices cannot assess the damage without knowing which specialties gain and which lose. CMS should be required to publish that analysis before any decisions are made. 3. Respond to the employed physician modifier RFI with real cost data, and support a statutory definition of independent practice. CMS has asked independent practices to quantify what independence means financially. That might include malpractice premiums, billing staff, credentialing, scheduling, and physician compensation structures not backed by a health system. Submit those numbers but recognize that a CMS administrative definition is inherently unstable, CMS can revise it in the next rulemaking cycle, and it will not capture MSO-controlled practices with nominal physician ownership that are functionally employed without being formally so. I propose defining independent practice with legislation, requiring majority physician ownership and freedom from non-physician entity control over compensation, coding, billing, contracting, and clinical standards. 4. Challenge the 28% post-op utilization rate. The global surgery rebalancing CMS is working toward is built on the assumption that only 28% of expected post-operative visits actually occur. Phone calls, portal messages, prescription refills, wound care guidance, therapy coordination all happen inside the global period, none of it is separately billed, and none of it is in the 28% figure. Surgical specialty societies should submit comment letters documenting actual post-op contact rates from independent practice data. These spark some legislative fixes as well: 1. Pass the Patients First Act before January 1. One day after CMS released this proposed rule, Reps. John Joyce, MD, Greg Murphy, MD, and Kim Schrier, MD, introduced the Patients First Act. It ties the conversion factor to the Medicare Economic Index minus one percentage point, caps year-to-year swings at 2.5%, and expands the budget-neutrality threshold from $20 million to $57.6 million with inflation adjustments. That threshold expansion slows CMS from clawing back value from procedural and surgical specialties every time it adds new codes. The bill also creates a statutory notice-and-comment requirement before any mandatory payment model is introduced or changed, a direct protection against what happened with the Ambulatory Specialty Model. 2. Support the MIPS-to-POINTS transition with independent practice protections built in. The Patients First Act replaces MIPS with a new framework called POINTS, with a five-year transition, reduced penalty range, and clinician-led quality metric development. As the bill moves through committee, independent physician organizations should engage to ensure the transition period includes protections for small and independent practices that lack the administrative infrastructure of large health systems, and that the quality metrics selected reflect the realities of independent practice rather than health system reporting capabilities. 3. Protect independent practice infrastructure in any PE reform. If Congress acts on Medicare payment this year, it should direct CMS to collect direct cost data from independent physician practices before finalizing any PE methodology overhaul, rather than relying solely on claims-derived utilization data. Comment docket: CMS-2026-2377 at regulations.gov. Deadline: September 14, 2026.