Over the previous few years, the enterprise of emergency medication has basically shifted. Suppliers have weathered nationwide crises—from the opioid disaster to the COVID-19 pandemic—whereas additionally managing a pointy rise in affected person acuity. However whereas the workload has elevated, reimbursement has not. Cost for emergency care has dropped to unsustainable ranges, placing the monetary stability of our security internet in danger.
As we glance towards 2026, the panorama for emergency medication reimbursement is shifting as soon as once more. New federal rules and aggressive industrial payer ways are converging, pushing unbiased practices and hospital-based doctor teams into an much more difficult monetary atmosphere.
State of the EM business: An unraveling security internet
To grasp the severity of those reimbursement challenges, we will study current research printed by the RAND Company, which analyzed over 50 million EM skilled claims from 2018 to 2022.
Throughout this era, skilled funds have dropped throughout the board:
- Out-of-network reimbursement is down 47.7%.
- In-network reimbursement is down 10.9%.
- Medicare funds fell 3.8% throughout the research interval.
However, when trying again over an extended timeline, Medicare funds are successfully down greater than 30% in comparison with 2001 when adjusted for inflation.
In stark distinction, facility funds have elevated greater than 18% throughout this similar interval. That is largely as a result of hospitals obtain annual changes tied to inflation and the rising value of care, mechanisms that doctor funds largely lack.
These traits have solely escalated because the research interval and are anticipated to proceed with new updates in 2026, with small and unbiased group practices feeling the brunt of this impression. As a result of they function independently of hospital methods, they haven’t any entry to the ability revenues that hospitals accumulate, leaving them uncovered to the impression of declining skilled funds.
Business payer traits: The rise of downcoding and “black field” denials
Business payers are more and more counting on aggressive cost-containment methods that straight erode doctor income. One of the crucial pervasive points is downcoding—when a payer unilaterally reduces the reimbursement quantity for a submitted declare.
The rise of AI-driven automation has accelerated this pattern, as payers now deploy software program to routinely flag and downcode claims based mostly on closing diagnoses or predictive analytics. Sadly, these automated opinions usually battle with the complexity and urgency of emergency care, failing to understand scientific nuances or seize essential affected person context. The outcome has been a sudden rise in downcoding and denials that ignore the fact of the affected person encounter.
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Prognosis-driven downcoding
Payers are more and more utilizing Low-Acuity Non-Emergent (LANE) lists to scale back reimbursement for diagnoses they deem non-emergency associated. The record of particular diagnoses is usually based mostly on analytics offered by consulting companies comparable to Mercer, which developed the Mercer LANE Evaluation methodology.
This follow—utilized by main payers together with Kaiser Permanente (Washington), Higher Peninsula Well being Plan (Michigan), Horizon Blue Cross Blue Defend (New Jersey), Windfall Well being Plan / Well being Assurance (Oregon)—basically ignores the resource-intensive workup usually required to rule out life-threatening circumstances earlier than a minor analysis may be confirmed.
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“Black field” software program algorithms
Different payers are going past a easy LANE record and deploying proprietary AI instruments that perform as “black packing containers,” obscuring the logic behind denials whereas drastically rising their frequency. A 2024 Senate report cited by the AMA discovered that these AI instruments can deny claims at charges as much as 16 occasions greater than these of conventional evaluation processes.
UnitedHealthcare (UHC), as an illustration, employs the Optum EDC Analyzer to evaluation claims. And, whereas their course of for doctor funds stays a thriller, their facility coding coverage suggests the algorithm depends closely on diagnosis-based components comparable to presenting issues and affected person complexity. Equally, Elevance Well being-affiliated plans (comparable to BCBS) use Cotiviti for automated declare enhancing.
This widespread reliance on murky algorithms shifts the burden of proof completely onto suppliers, making a “responsible till confirmed harmless” dynamic the place practices should take in the executive prices of interesting routine, automated denials.
States taking motion on payer downcoding
The rising prevalence of automated downcoding has prompted motion from some state regulators:
- Arkansas and Virginia adopted new downcoding legal guidelines this yr.
- Ohio, New York, Connecticut, New Jersey and Utah are at the moment debating comparable measures.
Whereas these efforts sign momentum, business leaders emphasize the necessity for balanced regulation. Automation and AI are highly effective instruments for income cycle effectivity—offered they don’t seem to be used to arbitrarily deny or cut back reliable cost.
Payers rollout new penalties for out-of-network suppliers
Business payers additionally proceed to evolve their cost-containment methods, elevating new considerations for unbiased emergency medication teams. A very regarding pattern is rising as some payers roll out insurance policies designed to penalize facility funds when out-of-network (OON) suppliers are concerned.
These insurance policies at the moment exclude emergency medication, however there’s nonetheless a danger that this exemption might change over time. If expanded, these insurance policies might allow coercive contracting, pressuring unbiased EM teams to simply accept unfavorable charges to guard their hospital companions from monetary penalties.
Medicare doctor reimbursement: Updates coming in 2026
Medicare reimbursement additionally faces its personal systemic challenges. CMS has constantly failed to regulate doctor reimbursement for inflation. As a substitute, emergency medication has confronted repeated cuts to the Medicare Doctor Payment Schedule (PFS), with the 2026 rule modifications introducing a mixture of non permanent reduction and long-term danger.
2026 Medicare PFS updates for emergency medication
Legislative protections by way of the 2026 Persevering with Appropriations Act
The 2026 Persevering with Appropriations Act (H.R.5371) offers funding for particular packages by means of January 30, 2026, providing non permanent assist to doctor funds:
- Medicare Geographic Value Value Index (GPCI): The Act restores the 1.0 flooring for the GPCI, stopping cost cuts based mostly on geographic location.
- Medicare Telehealth: It maintains originating website protections for Medicare Telehealth providers.
These measures present short-term reduction however don’t alter the long-term trajectory of doctor cost, which continues to pattern downward until Congress enacts structural reform.
The No Surprises Act: Progress, challenges and enforcement gaps
The No Surprises Act (NSA) basically shifted the reimbursement panorama for emergency medication. Previous to the regulation taking impact, many payers aggressively ramped up efforts to renegotiate contracts to unreasonably low charges and, in some circumstances, outright canceled good, long-standing contracts with supplier teams.
The NSA created a disincentive for payers to be in-network with some EM supplier teams, particularly since early IDR guidelines largely benefited OON payers. Since then, a number of TMA lawsuits have helped degree the taking part in discipline inside IDR, making it a extra cheap course of for a lot of teams.
Unbiased Dispute Decision (IDR) is working—when enforced
- Suppliers win greater than 80% of IDR circumstances.
- But in 2024, 59% of rulings weren’t paid inside the 30-day requirement, and 26% have been underpaid, in accordance with an EDPMA member survey.
This lack of enforcement permits insurers to side-step current regulation, creating vital money circulate disruptions and monetary pressure for a lot of EM teams.
Thankfully, Congress has taken word. In July 2025, Congressman Greg Murphy launched a bipartisan invoice aimed toward closing enforcement gaps by means of elevated penalties and transparency—an encouraging sign that lawmakers are starting to grasp these challenges.
What can we do about it?
Whereas many components in 2026 will stay outdoors of our management, EM teams nonetheless have significant levers they’ll pull.
- Get entangled in IDR: Whereas there’s a gradual ramp-up interval and administrative prices to think about, the outcomes are overwhelmingly optimistic for individuals who could make this a routine a part of their RCM course of. However restoration timelines are lengthy, so the earlier a bunch engages on this course of, the higher. Strategic IDR companions may present the experience and know-how to arrange and scale these efforts.
- Strengthen documentation practices: Exact, detailed documentation is the strongest protection in opposition to algorithmic downcoding. Clearly capturing complexity, danger and medical decision-making—together with considerate analysis wording—helps assist the suitable degree of service.
- Advocate and keep engaged: Momentum is constructing amongst policymakers and researchers. Becoming a member of organizations comparable to ACEP and EDPMA, taking part in surveys and contributing to advocacy efforts be sure that clinician voices are represented.
By specializing in operational effectivity and chronic advocacy, EM teams can higher navigate the headwinds of 2026 and proceed to offer the life-saving care their communities depend on.
