With the impending 2026 Medicare fee cuts and new CMS mandates, safeguarding your practice’s financial health has never been more important.
Beginning January 1, 2026, theCenters for Medicare & Medicaid Services (CMS)will implement a 2.5% “efficiency adjustment”cutting payments for thousands of specialty procedures, including orthopedic surgeries and pain management interventions.
According to theCMS 2026 Medicare Physician Fee Schedule Final Rule (November 3, 2025), this reduction reflects CMS’s belief that technology and workflow improvements have made many procedures more efficient. But for specialty practices, it adds more pressure to already tight margins.
The Impact: Less Pay, More Pressure
The 2026 rule includes several major shifts for which orthopedic and pain management practices must prepare:
- 2.5% efficiency cut for non–time-based procedures (surgeries, injections, outpatient interventions).
- Facility-based services will see additional reductions due to updated expense assumptions.
- Primary care gains funding as CMS realigns reimbursement priorities.
- Specialty groups— including orthopedics and pain management — warn that these cuts ignore the realities of patient complexity and modern clinical demand.
The American Medical Association (AMA) has voiced concern that CMS’s “efficiency” assumptions are flawed, relying on subjective survey data and penalizing procedural specialties. Meanwhile, primary care advocates support the changes as a step toward more equitable reimbursement.
The Broader Medicare Picture: The Good and the Bad
The Good
- Drug cost reductions:Medicare can now negotiate prices for certain high-cost drugs; lower costs start in 2026.
- Out-of-pocket cap:Part D annual prescription cap set at$2,100.
- Slightly lower Medicare Advantage premiums are projected.
The Bad
- Physician payment cuts:Especially for specialists performing surgical and outpatient services.
- Higher Part B premiums anticipated in 2026.
- Reduced plan flexibility:Some insurers will narrow networks or reduce perks.
While patients may see modest savings, specialists face declining reimbursement making operational efficiency and billing precision more critical than ever.
Key Steps for Orthopedic and Pain Management Practices
1. Identify Your Exposure2. Plan for revenue gaps by determining which of your codes and services will be most impacted by the2026 fee adjustments
3. Automate Claims and Workflows
4. Use AI-driven billing automation to reduce administrative burden and claim errors
- Streamline Prior Authorization
- Prepare for the newWISeR model, which adds PA requirements for many orthopedic and pain-related outpatient procedures.
6. Use analytics to spot underpayments, track denial reasons, and negotiate stronger payer contracts.Predictive analytics, if you have it, will be more important than ever to help you circumvent upcoming problems.
7. Partner with RCM Experts
8. The right revenue cycle management (RCM)partner ensures compliance, accelerates reimbursement, and provides the analytics and KPIs you need, all to keep your financial and operational performances resilient.
8. The right revenue cycle management (RCM)partner ensures compliance, accelerates reimbursement, and provides the analytics and KPIs you need, all to keep your financial and operational performances resilient.
How ADSRCM Helps You Stay Ahead
Advanced Data Systems (ADS)empowers orthopedic and pain management practices to thrive despite regulatory and reimbursement headwinds.
OurAI-powered Revenue Cycle Management platform(MedicsPremier) expedites coding, has a prior authorizations option, and works to help accelerate payments. Use the ONC-certified, specialty specific MedicsCloud EHR or retain your existing EHR interfaced with us.
ADSRCM delivers:
- Faster collections and reduced AR days
- HCFA, UB, workers compensation, no-fault, and personal injury claims
- Attorney management, an attorney self-serve portal, lien management, and more
- Case-specific patient management
- AI-assisted coding and claims accuracy
- Real-time analytics to spot payer trends
- Specialty-trained billing teams for orthopedics and pain management
- Compliance alignment with CMS, AMA, and MIPS updates
- Interfaces with virtually any PACS for images
Human expertise and AI precision are combined by us to help your practice collect faster, cut denials, and stay compliant even as payment models evolve.
The Bottom Line
The2026 Medicare Fee Schedule shifts the landscape toward efficiency and value, but at a cost for specialty providers.
By embracingAI-driven automation, improving claims workflows, and partnering with trusted RCM experts like ADSRCM, orthopedic and pain management practices can safeguard their revenue and maintain financial health amid Medicare’s next wave of change.
Learn more:adsc.com/revenue-cycle-management