From individual surgeon clawbacks to larger CMS repayment plans, insurance takebacks are reshaping the economics of medicine.
For spine surgery, clawbacks have been a persistent area of friction, Brian Gantwerker, MD, of The Craniospinal Center of Los Angeles, said.
“I had to do a surgery on a patient that involved a vascular surgeon getting into the abdomen to place an artificial disc,” he told Becker’s. “In order to do that safely, you have to employ the services of an approach surgeon. But the insurance decided to send a letter and say I didn’t need the approach surgeon. What we’ve seen now is new levels of dishonesty and clawbacks from the insurers, and there’s a lot of problems right now with physicians getting paid. It’s going to lead to more and more issues with physicians staying independent and staying in-network.”
Beyond spine surgery, clawbacks have become a point of contention for hospitals and health systems. In July, CMS proposed a rule for the 2026 hospital outpatient prospective payment system that includes a $7.8 billion clawback plan. The repayment plan would require hospitals to return $7.8 billion in overpayments related to 340B non-drug services, a move that health systems and the American Hospital Association have opposed.
Outside advocacy, leveraging AI is one way surgeons can buffer against the strain of clawbacks during the prior authorization process, Dr. Gantwerker said.
“If you have a prior authorization being run by an algorithm, you’ve given the algorithm for the CPT codes you’re going to use, and you turn in a claim with those with those codes, and the number that you’re going to get from the insurer is baked into that, then the insurer should have no reason to try to claw back money,” Dr. Gantwerker said. “You submitted a clean claim with the codes that you said you were going to use, the documentation supports it.”
And in the office, Dr. Gantwerker said patient education is another important tool to push back against insurer challenges.
“Insurance companies, by and large, don’t tell patients what they are entitled to, because if the patients realize that, then they become empowered, and therefore a threat to the company’s bottom line,” Dr. Gantwerker said. “I think if those clawbacks happen, we should inform our patients, and we’re doing that now.”
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