A Message from the CEO: The 2026 Reimbursement Crisis and ASTRO’s Response

The first quarter of 2026 has brought significant financial instability and uncertainty for many in our field. The 2026 payment rules for both the Hospital Outpatient Prospective Payment System (OPPS) and, especially, the Medicare Physician Fee Schedule (MPFS) introduced numerous fundamental changes. While the full impact of these changes may take months or even longer to fully understand, the struggles faced by radiation oncologists and cancer centers are real and immediate — and merit immediate action.

It is important that we review the history of how we arrived at this point, examine the current impact of these changes, and clearly outline ASTRO’s path forward.

How We Arrived Here

Radiation oncology experienced a substantial increase in billed charges between 2002 and 2014, primarily driven by the increased clinical appropriateness of intensity modulated radiation therapy (IMRT) in a larger number of cases. In 2014, the Centers for Medicare and Medicaid Services (CMS) declared that technical delivery charges were overvalued and requested a new approach. The AMA Current Procedural Terminology (CPT) Editorial Panel and RVS Update Committee (RUC) developed a new methodology, but unfortunately, it was rejected by CMS. Consequently, temporary G codes for delivery in the freestanding setting were created.

In 2015, the Patient Access and Medicare Protection Act (PAMPA) legislation then introduced a rate freeze for several years to facilitate the implementation of a new payment model. ASTRO played a significant role in the rate freeze. We diligently collaborated with the Center for Medicare and Medicaid Innovation (CMMI) to create a viable alternative payment model (coined the RO Model) intended to bring stability, predictability, and modest cost savings. However, when it became evident that CMS was pursuing extensive cuts rather than stability, we withdrew our support. After CMS placed the RO Model on an indefinite hold, their cuts resumed.

"...the struggles faced by radiation oncologists and cancer centers are real and immediate — and merit immediate action."

On the freestanding side, we have witnessed declines in reimbursement exceeding 25% over the past decade. Clearly, this situation is unsustainable, and we have actively advocated for payment reform through the radiation oncology case rate (ROCR) proposal. Although we have garnered substantial support for ROCR across various interest groups (130 and counting) and many members of Congress, the current political climate has not yet provided a legislative vehicle for its passage.

The 2026 Revaluation: Positives and Negatives

In 2025, the radiation treatment delivery and image guidance codes saw major changes. These changes reflect advances in technology and care delivery, which dramatically impact how these services are valued. ASTRO was actively engaged in the CPT and RUC processes, advocating for radiation oncology’s unique needs to be accounted for in these discussions. While the specific details of the CPT and RUC process remain confidential, several noteworthy outcomes emerged from this revaluation.

The Positive:

• MPFS has consistently faced the challenge of accurately capturing practice expenses for our specialty. There was a substantial risk that we would be categorized under diagnostic imaging, leading to significant reductions in our practice expense reimbursement. We were heartened to see CMS acknowledge that practice expense for equipment and specialized staff is not different between OPPS and MPFS. This led to MPFS technical payments being linked to hospital ambulatory payment classifications (APCs).

The Negatives:

• The 2026 MPFS rule has many components that work in varying ways, resulting in an inability to make apples-to-apples comparisons year over year.
• Collapsing into three treatment delivery codes and bundling image guided radiation therapy (IGRT) makes appropriate APC designation for the codes under OPPS of paramount importance since MPFS technical payments are now linked to OPPS. ASTRO continues to believe that 77407 was placed in the wrong OPPS APC, resulting in significant undervaluation of the code. Reimbursement for IMRT treatment for prostate cancer, the “typical” case for 77407, has decreased by 14%. This is a profound change.
• The definition of 77412 is quite specific and hence its utilization is far less frequent in practice than was predicted. CMS originally had it at 45%, but it was reduced to 35% in the final rule after public feedback. In many practices, including my own, utilization of that code has been less than 15%.
• CMS estimated that overall MPFS would see an aggregate cut of 1%. To many of us, this was quite difficult to reconcile with what was being presented. The professional codes saw an overall increase, but the technical codes, which make a much higher percentage of total charges, saw significant cuts. Hence, -1% was always suspect. Both hospitals and freestanding centers are seeing major cuts on the technical side.

The Immediate Impact on Our Field

In the first two months of this year, we heard major concerns from our members. This resulted in a survey of impact of the 2026 payment rules that was sent to members across the country. The findings are as follows:

• While hospitals are seriously impacted, the impact is felt most significantly by doctors at freestanding, independent practices and those in rural areas.
• In the freestanding setting, two-thirds reported decreases of 10% or more. This is not a minor adjustment. It is a destabilizing shock.
• Many doctors report that health insurance companies were unprepared for the transition (i.e., could not process the new codes), introducing additional delays, holds and denials. One respondent said processing time has doubled for many of their patients.
• Half of the survey respondents said advanced radiation treatments are frequently denied by insurance companies, causing unnecessary delays and anxiety for patients. Denials are especially common at freestanding centers.
• Private payers and benefit managers are exacerbating the tenuous situation with additional prior authorization requirements, downcoding even when documentation exists, and failing to update payment rates appropriately. Continued payer behavior such as this will have dire consequences.

We have heard of two centers closing, many centers and practices struggling to meet payroll, and radiation oncologists who have not been able to cover their own salaries. In some situations, physicians have been laid off. This is clearly disheartening. We shared these stories with policymakers and will continue to do so forcefully.

ASTRO’s Ongoing Actions

Here are the steps ASTRO has taken thus far, and what we intend to do moving forward:

• Providing regular membership updates via ASTROgram, ROhub, podcasts, and other communications channels
• Met with CMS staff to stress the crisis-level impact the coding and reimbursement changes are having on RO practices and submitted written comments to CMS leadership with policy solutions to help remedy the situation
• Lobbying Congress on how this crisis will impact patients’ access to radiation therapy, particularly in rural and underserved areas
• Heavily advocating with payers nationwide to ensure appropriate implementation and reimbursement rates for the revised codes
• Created a new Payer Support and Resolution Center as a one-stop shop to keep members apprised of updates related to the revised delivery codes and report payer issues to ASTRO staff
• Contacted Medicaid Directors in every state to notify them of the need to update their respective fee schedules and billing systems
• Hosting a Town Hall on May 6

Conclusion

Reimbursement concerns are not unusual in our field, but this time it is truly different. It is frankly a crisis. Center closures, physician layoffs, and the inability to meet payroll have created an existential threat to the viability of some practices. That impact affects access to care, technology maintenance and upgrades, and innovation.

CMS identified IMRT as potentially misvalued in 2012. They have cut reimbursement already by over 25% — cuts that were unjustified, as we have repeatedly stated. Having already absorbed those reductions, there is absolutely no justification for what is happening now. Ultimately our patients lose.

Because of this, ASTRO’s Advocacy Day on April 27-28 is especially critical. Please join us now and in the weeks and months to come as we make our voices heard. I am calling upon you to act by petitioning CMS Administrator Mehmet Oz, MD, directly.

I cannot promise success, as lobbying is always unpredictable, but please know that we understand and feel your pain. ASTRO will not rest until this is rectified.

Best regards,
Vivek S. Kavadi, MD, MBA, FASTRO