Could Your Surgeons Be in a Mandatory Model in 2027?
What orthopedic practices need to watch in federal policy right now
One physician in your group can be pulled into a five-year mandatory two-sided risk model starting in 2027 while their partners in the same practice are not. Nobody from CMS is going to call and tell you. Enrollment happens at the TIN-NPI level, so it lands on individual physicians rather than the group.
That is the Ambulatory Specialty Model. It was one of several items Claire Ernst, our lobbyist, walked through in her federal policy update at conference, plus it is a good illustration of the problem administrators face with federal policy generally. The decisions get made at a level of detail that never surfaces in a headline, the timelines are short, then the consequences arrive at your practice as a reimbursement change or a reporting requirement somebody has to absorb.
Most practice executives do not have time to read proposed rules. You should not have to. That is the job we have taken on: Claire tracks it, we translate it, then it reaches you through our newsletters before it reaches you as a problem. What follows is the current working version.
Two dates that belong on your calendar
September 30 is the funding deadline. The 119th Congress has a narrow window before members leave to campaign for the November midterms, which compresses everything else on the legislative track. Anything that does not move before that window closes is competing for attention against an election.
December 31 is the one that hits reimbursement directly. The GPCI floor expires unless Congress extends it, which means cuts for practices in lower-cost localities. The geographic practice cost index adjusts payment based on where you operate, so the floor protects practices in areas the formula would otherwise underpay. If your practice sits in one of those localities, this is not an abstract policy question, it is a line in next year's budget.
The participant list you should check this week
The Ambulatory Specialty Model begins in 2027 as a mandatory two-sided risk model covering 25 percent of the country. Roughly 950 surgeons are on the preliminary participant list. Physicians treating 20 or more qualifying chronic low back pain episodes a year get pulled in.
Two-sided risk means the practice can lose money on performance, not just fail to earn a bonus. Mandatory means there is no opt-out. Because enrollment happens at the individual physician level, a group can have one partner inside the model with everyone else outside it, which creates a reporting plus workflow problem nobody planned for.
Check whether any of your physicians are on that preliminary list. Then check again after the final rule, because preliminary is not final.
What CMS still needs to hear from you
The MVP that CMS selected for low back pain was built for chiropractors plus non-physician providers, not surgeons. That mismatch is exactly the kind of thing that gets fixed at the comment stage or not at all.
CMS has also issued requests for information on whether ASCs plus physician-owned hospitals should be pulled into the TEAM model, which would extend bundled payment accountability to settings that have not carried it before.
Comment letters are being written right now. What makes them land is specifics from real practices: what the measure actually asks of your physicians, what the reporting costs you in staff hours, where the model breaks down in a practice like yours. The proposed Physician Fee Schedule arrives in July, so the window for shaping those letters is short. Send your examples to the Advocacy Council.
Nobody is going to send you the participant list.
Comment windows close, participant lists post, then deadlines pass whether or not anyone at your practice was watching. AAOE Quick Bites is our LinkedIn newsletter, where policy changes like these get broken down as they happen, in the time you actually have. Subscribe here: [Quick Bites link]
Enforcement is widening
The CRUSH RFI, the WISeR model, plus a six-month national moratorium on new DMEPOS enrollments all point the same direction. Fraud and abuse enforcement is expanding, with home health flagged as a possible next area.
The piece most administrators miss is affiliation risk. Entities have been removed from Medicare for ten years over conduct by associated providers they had no involvement with. If your practice has ownership ties, management relationships, or shared billing arrangements, that exposure is worth mapping before someone else maps it for you.
RADV audits in Medicare Advantage are also moving toward extrapolation. Rather than recouping on the sampled charts, the auditor projects the error rate across the population, which turns a small sample finding into a large repayment.
Where your practice story moves the needle
The current $20 million budget neutrality threshold under MACRO triggers across-the-board cuts to the conversion factor any time CMS makes a meaningful payment change. That is what happened with the 2021 evaluation and management increase: a policy improvement in one area produced a cut for everyone.
The Doctors Caucus is actively working on raising or eliminating that threshold, plus reducing MIPS reporting burden. Both of those depend on members of Congress hearing what the current rules cost real practices.
Congress moves on stories, not position papers. Yours is the story.
Prior authorization is going algorithmic
Under CMS Administrator Dr. Oz, the voluntary ACCESS model launched with a musculoskeletal track alongside a mostly technology-focused participant group. CMS has also released a vetted app library covering virtual assistants plus similar tools.
The direction is clear. Expect AI-driven prior authorization plus utilization management to expand. The risk for orthopedic practices is speed: an algorithm can generate denials faster than any human review process can appeal them, which becomes a patient access problem before it becomes a revenue problem. That is why guardrail advocacy at the practice level matters now, while the rules are still being written.
The easier door: state advocacy
State legislators answer their phones. Federal members rarely will.
Start by mapping the players in your state, including the groups working the same issues from a different angle. Search the bill database by keyword. Identify your district senators plus delegates as your entry point, then target the health committees where the bills actually move.
You are not building a second advocacy agenda to do this. Administrative burden and practice solvency cross both levels, so the case you would make to Congress is the case you make at the statehouse, to people far more likely to take the meeting.
How to stay ahead of the next one
Everything above will change. Rules get finalized, lists get revised, then a new deadline replaces the one you just cleared. Staying current is not a research project you take on once, it is a standing feed.
Here is where we put it.
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The full executive summary and recording from Claire's session is in the Learning Center with the rest of our advocacy content:
AAOE members also receive updates through the member newsletter, including blog posts directly from council members who are navigating these issues in their day-to-day work.
Then bring your Advocacy Council something concrete. We cannot make the case without on-the-ground reporting from the administrators living inside these rules.
Reach out to the AAOE Advocacy Council