The No Surprises Act: Protecting Patients, Reshaping the Anesthesia Landscape
When the No Surprises Act (NSA) took effect in 2022, it marked an important milestone for patient protection, shielding individuals from unexpected out-of-network bills. However, its implementation has introduced new complexities—particularly in how insurers and providers navigate reimbursement.
One major challenge for anesthesia practices has been the shift in payment dynamics. With balance billing curtailed, many insurers now offer reimbursement near the Qualifying Payment Amount (QPA), typically defined as the median in-network rate. While designed to standardize payments, this has, in practice, resulted in significantly reduced reimbursements for many anesthesia providers—often 40% below historical norms. The American Society of Anesthesiologists (ASA) has raised concerns about the impact of this change, particularly in situations where payment disputes can linger for months and providers have limited recourse.
This evolving landscape calls for a renewed focus on collaboration among payers, providers, and policymakers to ensure that the law achieves its goals without unintended consequences for healthcare delivery.
Adjusting the Model: Shifts in Anesthesia Reimbursement Practices
In addition to rate adjustments, some payers are reevaluating how anesthesia services are billed. UnitedHealthcare (UHC), for example, announced policy changes effective fall 2025 that include:
- A 15% reduction in reimbursement for CRNA-performed cases billed under the QZ modifier (when practicing independently),
- The removal of added units for higher-risk patients (ASA Physical Status P3–P5),
- And the discontinuation of units for “qualifying circumstances” like emergency cases or extreme age.
UHC noted that these changes align with CMS standards. However, anesthesia professionals point out that commercial insurers have historically recognized these modifiers to account for added complexity and risk.
Other insurers are adopting similar policies, and while some proposals have been rolled back in response to stakeholder feedback, the broader trend suggests a redefinition of how anesthesia work is valued—particularly in high-acuity cases. This may have downstream effects on provider participation and case coverage, particularly in time-sensitive or critical care settings.
Impact on CRNA Reimbursement and Rural Communities
One of the most closely watched changes is the reduction in reimbursement for CRNAs billing independently. Critics, including the American Association of Nurse Anesthesiology (AANA), argue that this shift undervalues the care provided by CRNAs, especially in regions where they serve as the primary anesthesia providers.
Rural communities across the Southeast are especially vulnerable. In many of these areas, CRNAs are the cornerstone of surgical and obstetric services. Reduced reimbursement may make it harder to recruit and retain talent, further straining rural healthcare systems already facing workforce shortages and tight budgets.
It’s essential for insurers, providers, and policymakers to recognize the role CRNAs play in ensuring access and to explore fair, evidence-based approaches that reflect both clinical quality and financial sustainability.
Addressing Legal and Ethical Considerations
UHC’s CRNA policy has also sparked discussion around legal and ethical frameworks. The Affordable Care Act prohibits discrimination in reimbursement against licensed healthcare providers operating within their scope. The AANA has raised concerns that this differential payment approach could run counter to that standard.
The debate raises important questions: Should the same service be paid differently based solely on licensure? And how can reimbursement policies be structured to reflect clinical value rather than provider type? These are complex issues, but ones that deserve thoughtful engagement from all sides to ensure fairness and alignment with federal regulations.
The Hospital Perspective: Financial Implications and Support Needs
Hospitals are increasingly finding themselves in the position of bridging the gap created by reduced payer reimbursement. In many cases, anesthesia groups that previously operated on commercial payment alone now require hospital subsidies to remain viable—especially for emergency coverage, trauma services, and rural facilities.
These added costs can be substantial. Health system leaders must consider how evolving payer policies may impact their overall financial strategy, from staffing to service line sustainability. Ensuring access to anesthesia services may require new partnership models and a proactive stance in reimbursement discussions.
A Converging Challenge: Payment Pressures Amid Workforce Shortages
Overlaying these financial and policy shifts is a growing shortage of anesthesia professionals. Estimates suggest that by 2036, the U.S. could face a shortage of over 6,000 anesthesiologists, along with thousands of CRNAs. This shortage is felt most acutely in rural and underserved areas, where recruitment is already difficult.
As compensation models shift and workloads increase, some clinicians may reconsider their participation in certain practice environments—especially if reimbursement does not reflect the acuity or complexity of care provided. In this context, fair payment isn’t just a financial issue—it’s a workforce and access issue as well.
Charting a Collaborative Path Forward
The changing reimbursement landscape presents both challenges and opportunities. While the No Surprises Act was crafted to protect patients, it’s essential to ensure that the implementation of related payment policies supports a sustainable care delivery model for all stakeholders.
DPI Anesthesia believes that the path forward requires active collaboration between providers, payers, hospital leaders, and regulators. Solutions may include clearer dispute resolution processes, more transparent rate-setting mechanisms, and alignment on the value of both physician and CRNA contributions to anesthesia care.
Our message to partners and policymakers is simple: preserving access to high-quality anesthesia care requires fair and thoughtful reimbursement practices. Let’s work together to ensure that the financial foundation of this vital specialty supports, rather than hinders, patient care—especially in the communities that need it most.
Sources:
- AANA – “AANA Condemns United Healthcare’s Unlawful, Discriminatory Anesthesia Reimbursement Changes” (Press Release, July 2, 2025)
- Becker’s ASC Review – “UnitedHealthcare slashes CRNA reimbursements: 5 things to know” (Francesca Mathewes, July 2025)
- UnitedHealthcare Commercial Reimbursement Policy Update (July 2025 Bulletin)
- Becker’s ASC Review – “Medical Mutual to reduce CRNA reimbursement; AANA calls move ‘dangerous’” (Claire Wallace, Dec. 20, 2024)
- ASA (American Society of Anesthesiologists) – Newswise: “ASA Proposes Nine Recommendations to Address Flawed Implementation of NSA” (Press Release, Nov. 15, 2022)
- VMG Health – “No Surprises Act Causes Growth in Anesthesia Coverage Payments at ASCs” (James Tekippe et al., Aug. 28, 2023)
- Anesthesia Experts/Becker’s – “The anesthesia reimbursement problem in 10 numbers” (Patsy Newitt, Apr. 14, 2025)