Here's what Healthcare Administrative Partners is monitoring for 2026:
The Medicare Physician Fee Schedule (MPFS) Final Rule for 2026
The MPFS Final Rule was mostly unchanged from what was proposed a few months earlier. The conversion factors for 2026 Medicare reimbursement were proposed to be an increase of 3.3% to 3.8%, and the final figures came within that range but slightly lower by fractions. Payments for 2026 will depend on whether the physician is considered to be a qualified professional (QP) or a lower-paid non-QP based on their participation in an Advanced Payment Model (APM). The Efficiency adjustment and the Site of Service adjustment were finalized. The latter will not negatively impact hospital-based diagnostic radiologists, but it could favor nonfacility (offices or OBL) services.
Sandy Coffta.
Medicare’s estimates for the impact on radiology are -3% for hospital services and +1% for nonfacility. Interventional radiology (IR) in the hospital is hit harder than diagnostic radiology (DR) because the Efficiency adjustment that reduced all facility-based services by 2.5% will not apply to Professional Component (modifier -26) billing. Therefore, the practice’s IR/DR mix will make a big difference in the outcome. Our preliminary volume-weighted analysis shows substantial decreases for IR in the hospital setting (5%-15%) compared with modest increases (0.5%-2%) on the DR side in both hospital and nonhospital services. We are seeing increases of 3%-7% for IR services in outpatient offices and OBLs. Our full impact analysis will be coming out soon.
Quality Payment Program (QPP) results for 2024 participation
The reimbursement reward for Merit-based Incentive Payment System (MIPS) participation continues to be low, but avoiding the 9% payment penalty for not participating is worth the effort. The maximum positive incentive adjustment for 2026 (based on 2024 results) will be 1.05%. Hardship exemptions for cyber attacks and natural disasters were available that allowed some practices to avoid penalties, thus reducing the pool of funds available for positive adjustments.
Anthem out-of-network policy
Anthem (also known as Elevance Health) has implemented a policy that would charge hospitals a 10% administrative fee for their claims that involve out-of-network (OON) physicians. The policy has the effect of giving hospitals leverage to force radiologists to accept network agreements that they otherwise might not. The American College of Radiology (ACR) is one of several specialty societies opposed to the policy, and the ACR has urged Anthem/Elevance to reconsider it.
Supplemental breast imaging
Pennsylvania recently joined thirty other states that require health insurers to cover MRI and ultrasound imaging for patients following abnormal mammograms. Under the Pennsylvania law, there will be no out-of-pocket charges for “Diagnostic breast examinations for a covered person whose risk level for breast cancer is determined to be at least average risk or higher.” The law was signed in November 2025, and it becomes effective in late January 2026.
At the national level, the Find It Early Act, which was first introduced in 2022, continues to be promoted bilaterally. It was reintroduced in the House in 2025 but has yet to be considered for a vote. Its provisions would provide a federal mandate similar to what is already in effect across most of the country.
United Healthcare's prior authorization policy
United Healthcare no longer requires prior authorizations for certain nuclear imaging, obstetrical ultrasound, and echocardiogram procedures as of January 1, 2026. According to the UHC Bulletin, this policy change includes their commercial as well as Medicare Advantage plans.
Head CT in emergency departments has doubled between 2007 and 2022
A study reported in the journal Neurology, published November 19, 2025, confirms a trend that has been reported anecdotally by many radiologists. The increasing use of CT in the ED is a major volume driver that doesn’t necessarily result in revenue. While the exams are generally reimbursed by payers, overall reimbursement can be low due to such things as bad insurance information or lack of medical necessity.
Appropriate Use Criteria (AUC)
Medicare finally decided in 2023 not to pursue its planned penalties on radiologists for the failure of ordering physicians to consult clinical decision support (CDS) systems. New legislation has been introduced that would revive the plan to require the use of AUC/CDS by ordering physicians through a retrospective audit program to ensure compliance. The ACR has voiced its support for the proposed legislation, as auditing ordering physicians would place the responsibility for AUC/CDS usage and the consequences for failure to use it in the correct venue, rather than penalizing radiologists who have no control over it.
Conclusion
We closely monitor evolving trends in medical practice and reimbursement, particularly those impacting radiologists. Subscribe to this blog for all the latest information that affects your practice’s reimbursement.
Sandy Coffta is the vice president of client services at Healthcare Administrative Partners.
The comments and observations expressed are those of the author and do not necessarily reflect the opinions of AuntMinnie.
