Articles

Presentation took place September 22, 2025

Independent ED Physician Coalition – 2025 Reimbursement, Regulatory & Advocacy Updates for EM

Dr. Ed Gains, JD, CCP, VP of Zotec Partners

1. Zotec Partners Overview
   Founded: 1998 by T. Scott Law, CPA | HQ: Carmel, IN.
   Scale: 30,000+ clinicians | $8B+ collections | 130M procedures | 12M ED visits annually
   Core: Proprietary SOC-1 and HITRUST certified RCM platform serving all specialties.
   Among largest privately held U.S. RCM companies.
   Mission: “Leading the way to improve the business of healthcare for everyone.”
2. Zotec Advocacy & ZPAC
   7,640+ advocates nationwide sent 55,986 messages to lawmakers.
   The advocacy team tracks hundreds of bills affecting business and reimbursement,
   ZPAC (Zotec Political Action Committee): Interactive grass-roots tool enabling clinicians to influence state and federal policy.
   Regular updates on legislation impacting clinicians and patients.
3. 2026 Medicare Physician Fee Schedule (MPFS) Proposed Rule
   Released July 14, 2025; final rule expected Nov. 2025; effective Jan. 1, 2026, but the final
   rule could be delayed due to the federal government shutdown.
   Conversion Factors (CF):
   Split CFs under MACRA:
   – MIPS physicians: +0.25% update.
   – Advanced APM participants: +0.75% update.
   2026 CFs (proposed):
   – A-APM = $33,5875 (+3.83%).
   – MIPS = $33,4209 (+3.32%).
   – Includes +2.5% temporary OBBBA bump and +0.55% budget-neutrality adjustment.
   2025 payments fell 2.83% as 2024 temporary relief expired; no current bill fixes that cut.

Special Impact (Table 92 estimates)

Specialty Combined Impact
Emergency Medicine ≈ -1% overall (-2% facility / +7% non-faculty)
Anesthesiology -1%
Critical Care -4%
Radiology / IR ≈0 to +2% range
(excludes CF, sequestration, PAYGO effects)

Efficiency Adjustment Proposal
New -2.5% reduction to work RVUs & intraservice time (non-time-based codes).
Based on assumed “efficiency gains” over time; uses 5-year MEI look-back
Exempt from cut: E/M, care management, behavioral health, telehealth codes.
Depending on the procedures, there may be significant cut in procedure reimbursements.
Estimated -1% overall reduction if finalized in 2026.

Additional Potential Reductions
PAYGO sequestration: returns in 2026 due to unfunded American Rescue Plan, unless Congress acts again.
Zotec advocating for permanent fix to prevent future cuts.

E/M and Practice Expenses Notes
ED E/M work RVUs unchanged from 2025.
Practice expense methodology revision may lower procedure reimbursement.
Net: slight increase in ED E/M, slight decline in procedures (variance by code mix). Overall EM reimbursement will be flat to slightly negative in 2026 if the proposed rule is finalized as it is in the proposed rule.

4. “One Big Beautiful Bill Act” (OBBBA)
   Adds +2.5% temporary CF increase for 2026 (expiring 12/31/26).
   Creates Rural Health Transformation Program (RHTP)
   – $50B investment – largest since 2003.
   – Addresses low volume, workforce, technology, and infrastructure needs.
   – 50% funds split equally to participating states; 50% by CMS formula.
   – Each state could receive ≈ $100M annually for 5 years.
   Strengthens rural hospital sustainability and state-clinician partnerships.
5. Continuing Appropriations & Extensions Act (H.R. 5371): Passed by the House but has not yet passed the Senate, hence the government shutdown.
   “Republican CR Stopgap Funding Bill” – extends key health programs through Nov. 21, 2025.
   § 206: Extends 1.0 work GPCI floor.
   § 207: Continues telehealth flexibilities.
   § 208: Extends Acute Hospital Care at Home waivers.
   § 209: Maintains Part D coverage for oral antivirals.
   § 401: Delays Medicaid DSH cuts until Nov. 21, 2025; remaining cuts FY26-28.
6. No Surprises Act (NSA) & Independent Dispute Resolution (IDR)
   Litigation & Regulatory Timeline
   Oct. 30, 2024: 5th Circuit en banc reversed TMA III panel decision.
   Sept. 24, 2025: Oral arguments before 5th Circuit en banc.
   Demonstrates continued instability in NSA implementation and physician burden.

IDE Process Highlights
Pre-IDR steps: open negotiation –> initiation –> selection of certified IDRE.
Federal IDR steps: submission of offers –> payment determination –> loser pays fees.

CMS Backlog & Eligibility Data
CMS reports significant progress in clearing backlog and reducing ineligible claims (see CMS Fact Sheet Sept. 2025).
FHAS data (Dec. 2024): ≈ 90% of claims now eligible for IDR.
ED E/M win rates: 85-90%, stable or improving.

Financial Impact
Typical IDR recoveries = 3-6x initial (QPA) payments.
Health plans must pay IDRE fees under “loser-pays” structure.
Successful IDR appeals help ED groups maintain hospital contracts and negotiate lower stipends.

7. Key Takeaways & Action Steps
   Expect continued volatility in Medicare rates through 2026 pending Congressional action on PAYGO & OBBBA expirations.
   Engage with ZPAC to advocate for long-term stability in physician payment.
   Monitor 2026 final rule (Nov. 2025) for RVU adjustments and efficiency factor finalization.
   Leverage IDR process aggressively – data shows high success and material ROI.
   Continue education on NSA litigation (TMA III/IV) and federal IDR reform proposals.