Radiology’s crossroads just became a fork in the road: RBMA leaders discuss the Medicare Physician Fee Schedule and what comes next

In November, we shared of our "Hopes and Concerns" for a second Trump administration. At the time, our reflections were speculative, anchored in campaign promises, political instinct and early signs of administrative direction. Since then, however, many of those themes have swiftly materialized into policy, first through the sweeping One Big Beautiful Bill Act and now through the proposed 2026 Medicare Physician Fee Schedule (MPFS). Still, we’d be disingenuous if we claimed to have anticipated the speed and scale of these changes. What once felt like distant possibilities are now rapidly reshaping the healthcare landscape.

Traditionally, the MPFS is an annual exercise in deliberate incrementalism. Most years, instead of barbecue and baseball, policy wonks quietly dig through hundreds of pages over the Fourth of July weekend to calculate the scale of reimbursement cuts to radiologists and other physicians. This year is different. This proposed MPFS is potentially one of the most meaningful policy shifts we’ve seen in many years and will take some time to fully unpack. The administration has picked sides and is determined to upend the status quo.

The most immediate takeaway is the redistribution of reimbursement between hospital and nonhospital settings. Nonfacility providers stand to receive modest gains. Facility-based providers, especially those in hospital systems, could face reductions or stagnation. In fact, some specialists are staring down new reimbursement deltas of 15% or more depending on site of service. While radiology is absolutely impacted by this trend, the delta is not as extreme as it is in other specialties. That said, the specialty impact tables make clear that radiology's reimbursement outcomes still hinge entirely on site of service.

This is intentional. CMS is using rule-making to accomplish what Congress has flirted with via the legislative process. The push toward site neutrality is no longer conceptual—it’s happening, quietly but unmistakably. A striking example appears in the proposed 2026 Medicare Physician Fee Schedule, where CMS states it is “proposing a major refinement to better reflect the practice setting shift among physicians,” citing data that just 35.4% of physicians still own their practices as of 2024. To correct for this trend, the agency proposes reducing the portion of indirect practice expense RVUs allocated through work RVUs by half for services performed in facilities. According to CMS, continuing to allocate indirect PE equally across settings may “overstate costs for facility-based physicians and distort relativity.” But here’s the problem: Most radiology groups are not “hospital owned.” They shoulder indirect expenses like those in nonfacility settings—yet under this proposal, they would be penalized to an extent simply by operating within a facility.

For decades, the American Medical Association’s CPT Editorial Panel and Relative Value Scale Update Committee (RUC) have quietly dictated how Medicare reimburses physicians. The RUC collects survey data from physicians and uses it to recommend time and intensity values for every procedure and service, and CMS has historically adopted those values. CMS considers these recommendations in the annual update to the Medicare Physician Fee Schedule.

In the 2026 proposed rule, CMS makes clear its growing distrust of physician-reported survey data, suggesting that such inputs are often shaped by self-interest rather than objective reality. The agency is signaling a shift away from narrowly sourced, industry-backed surveys toward broader, empirically grounded data sets. In CMS’ view, the current system has allowed providers to inflate time assumptions and resist efficiency gains, ultimately distorting the valuation of services and undermining the integrity of the fee schedule.

Using an axe as opposed to a scalpel, CMS is proposing a 2.5% cut to the work RVUs of nearly all procedures in 2026, citing productivity gains and inflated time assumptions. These efficiency adjustments would repeat every three years. And CMS is signaling that it wants to rely on actual billing data and broader empiric sources, not limited surveys that have been championed by industry groups, admittedly, including us at the Radiology Business Management Association. In essence, CMS is implying that practicing physicians are conflicted when, in reality, they are simply sharing real-world patient experiences, particularly in areas where empirical data are limited or unavailable. This proposed adjustment is particularly concerning for radiology, a practice which, with its array of advanced imaging techniques, plays a pivotal role in identifying cancer at its earliest stages. Each year, technological advancements make scans more sophisticated, resulting in a higher volume of images that must be reviewed. However, CMS overlooks this important distinction, maintaining its belief that non-time-based codes, such as those for procedures, radiology services, and diagnostic tests, should gradually become more efficient.

At the same time, protocols are becoming more complex and patient conditions more acute. These factors demand greater clinical expertise and time, not less—making a blanket efficiency cut both problematic and potentially detrimental to patient care quality.

The New York Times even took notice of this shift, representing a new life in the limelight for MPFS. In a recent article, they reported that the administration is moving to reduce the AMA’s influence and modernize payment formulas. CMS officials called it a correction to outdated assumptions.

The agency also is moving toward using hospital cost reports and auditable data to set technical rates for some services. Radiation oncology is the first to see this approach applied, but others may follow. This means less reliance on survey-based data, and potentially more volatility for those who have benefited from legacy assumptions.

Buried in the fine print but critically important for radiology and other specialties relying on advanced practice providers is CMS’ proposal to permanently adopt virtual direct supervision. The new rule affirms that immediate availability of a supervising physician can include real-time audio and video communications technology. This is a hard-fought win for the industry, including direct meetings by this piece’s authors with this administration and the last. It reflects how care is actually delivered across sites and settings, especially in rural and multi-site practices. It also acknowledges that technology, when applied safely, can expand access and flexibility without compromising patient care.

Taken together, the proposals in the 2026 MPFS are far from incremental. They represent a fundamental reorientation of Medicare policy in a way that rewards nonhospital providers, devalues traditional survey inputs, and leans heavily into skepticism and site-based relativism. This is not happening in a vacuum.  The One Big Beautiful Bill Act, passed earlier this year, has already reshaped the healthcare landscape with sweeping changes to Medicaid and the Affordable Care Act. This law imposes over $1 trillion in Medicaid cuts over the next decade, introduces strict work requirements, and tightens eligibility rules—changes the Congressional Budget Office estimates will leave up to 10 million people without coverage by 2034. 

We strongly encourage all readers to review the proposed rule and supporting data and to reach out with questions or concerns. Physicians, especially in radiology, must be assertive and strategic in their advocacy. CMS has made its intended direction clear, but this is still a draft rule, and the window to influence its final form is open. Now is the time to engage through public comment, direct dialogue with agency leadership, and coordinated congressional outreach. Legislative discussions around reimbursement reform are ongoing, and more will be needed if statutory clarity or guardrails become necessary. Practices that act now will help shape the future and be better positioned to survive it.

Linda Wilgus, MBA, is the co-executive director of the Radiology Business Management Association and Christopher “Kit” Crancer is chair of the RBMA's Radiology Patient Action Network.