As the reimbursements for spine and orthopedic procedures continue to stay stagnant, or drop in some cases, practices are working harder than ever to protect margins while ensuring top-quality patient care.
Taking site-of-service control, treating payer contracts as living documents and diversifying their income streams are a few of the ways that surgeons are keeping up.
These three spine and orthopedic leaders recently connected with Becker’s to discuss the strategies that high-performing practices are adopting in reimbursement negotiations with payers.
Note: Responses were lightly edited for clarity and length.
Question: What orthopedic and spine procedures are being squeezed hardest by current reimbursement changes, and how are high-performing practices protecting their margins without compromising care?
Ernest Braxton, MD. Partner of Vail (Colo.) Summit Orthopaedics and Neurosurgery: The procedures getting squeezed hardest right now are multi-level lumbar fusions and cervical disc arthroplasty in the Medicare Advantage population. The squeeze isn’t primarily rate cuts; it’s the combination of flat commercial rates, rising implant costs, prior auth burden and aggressive post-payment denial activity.
The practices protecting their margins share a few habits. They treat payer contracts as living documents, renegotiating per-CPT with current cost data. They actively use the federal No Surprises Act IDR process and state arbitration laws for legitimate out-of-network scenarios, particularly emergency and on-call coverage in hospitals. They’re rigorous about the true economics of call coverage rather than subsidizing it. And they diversify through ASC ownership, ancillaries and compliant industry relationships.
The practices losing the fight are the ones treating each denial as an isolated billing problem instead of a signal about a structural contracting issue.
Michael Gross, MD. Orthopedic Director of Union Middlesex Orthopedics (Woodbridge, N.J.): The pressure is hitting exactly where you would expect. It is concentrated in procedures where CMS has the most pricing leverage and where volume is high enough to attract scrutiny. That means total joint arthroplasty, spinal fusion and most facility-based orthopedic and spine surgery performed in hospitals and ASCs.
In my view, the current combination of fee schedule cuts and the new efficiency adjustment is not incremental. It is structurally changing the economics of these core procedures. At the same time, expanded prior authorization and prepayment review are adding real administrative friction. Practices are dealing with lower reimbursement on their highest volume work while spending more to actually collect that revenue. That is a difficult equation, especially for groups that rely heavily on facility based surgical income. The practices that are navigating this well are doing a few things very deliberately.
First, they are taking control of the site of service. They are moving appropriate cases into physician-owned ASCs and office settings wherever possible. Just as important, they are building out ancillary services such as physical therapy, imaging, DME and pain management. The reality is that the traditional work RVU model no longer captures the full value of a patient relationship. The groups that recognize that and act on it are in a much stronger position.
In addition, they are treating the revenue cycle as a strategic function, not an administrative one. Prior authorization performance, denial rates and clean claims are now material drivers of margin. The gap between average and top quartile performance in these areas has become meaningful enough to offset a portion of the reimbursement cuts.
Finally, they are far more selective with payers and service lines. That includes renegotiating commercial and Medicare Advantage contracts, walking away from unprofitable arrangements, and participating in bundled payment models when the economics actually work. In the past, many groups absorbed margin compression. That is becoming less viable.
What stands out to me is that none of this requires a compromise in clinical care. If anything, the highest performing practices are the ones pairing operational discipline with strong clinical consistency. The broader implication is hard to ignore. These reimbursement trends are accelerating consolidation. Larger groups and capital backed platforms have the infrastructure and capital to respond quickly. Independent practices are facing the same pressures without those resources, which is why more of them are exploring partnerships or alignment strategies.
I am also very concerned about the behavioral impact of sustained margin pressure. When reimbursement tightens this much, it does not just force efficiency. It changes behavior. It creates real incentives for aggressive marketing, loose clinical claims and revenue models that sit in the gray zone between innovation and exploitation, particularly in cash pay areas like orthobiologics. We are already seeing that play out. The risk is not theoretical. It is scaling. The practices that will ultimately separate themselves are not the ones that chase that pressure, but the ones that resist it. Holding the line on evidence and transparency is not just a clinical decision anymore. It is a strategic one, and it will define who patients, partners and payers trust over the long term.
James Rizkalla, MD. Clinical Assistant Professor of Orthopedic Surgery and Medical Director for Orthopedic Research of the Texas A&M School of Medicine and Baylor University Medical Center (Dallas): At Baylor Spine and Scoliosis, the biggest reimbursement pressure in spine and orthopedics is on complex, high-cost procedures, particularly revision spine surgery, deformity surgery and multilevel fusions, where implant costs, operative time and hospital resources continue to rise while reimbursement does not keep pace.
High-performing practices are protecting margins by improving efficiency rather than cutting corners. That includes better patient optimization, shorter hospital stays, more outpatient and ASC migration when appropriate, standardized implant utilization and minimally invasive techniques that can reduce complications and recovery time.
Another major challenge is the increasing administrative burden from prior authorizations and denials, which creates delays and inefficiency for both surgeons and patients. The practices that will succeed long term are the ones that can demonstrate excellent outcomes, operational efficiency and value-based care while still maintaining access for complex patients.
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