Not Business as Usual: 2026 Proposed Rule Changes Radiology

Andrew K. Moriarity, MD, ACR Radiology RUC Advisor was a guest author for Gregory N. Nicola, MD, FACR, in this "From the Chair of the Commission on Economics Column."

The 2026 CMS proposed rule arrives at a pivotal time for radiology. Payment policy is increasingly making significant changes to how imaging and interventional procedures are valued relative to other medical procedures and ultimately how our practices, the specialty and medicine are evolving and driving consolidation. Whether you practice in an academic department, a large multispecialty group or a single-specialty radiology practice, the rules changes proposed this year will matter even more than in the past.

ACR has reminded members that payment trends cannot be ignored and increasingly cannot be mitigated by tactics and solutions used in the past. Understanding what lies ahead is critical for every member because the consequences are matter for patient access, work force sustainability and the viability of the field.

Work RVU “Efficiency Adjustment”

CMS proposes a –2.5% across-the-board cut to work RVUs for codes not tied directly to physician time. This includes nearly all diagnostic imaging interpretation and many interventional procedures.

The rationale given is that there are “efficiency gains” inherent to medical procedures as the technologies progress. Our members, however, know this does not reflect reality. Imaging examinations and procedures are increasingly complex. There has been an increase in the number of comparison studies. Patients increasingly have greater comorbidities and multiple illnesses, requiring more careful interpretation of a greater number and complexity of imaging. Radiologists must take more time to perform these ever-advancing procedures — not less.

For example, a CT or MRI examination today can contain hundreds of more images or sequences and demonstrate pathology in much greater detail compared with just a few years ago, yet reimbursement continues to decline. At academic centers, this threatens already thin margins that support education and research. For community and private practices, it accelerates the pressure to read more with less time. No matter where you work, this has direct impact on professional value and the service we can provide to our patients.

Facility Indirect Practice Expense Allocator Cut

CMS also proposes halving the facility indirect practice expense allocator from 100% to 50%. This change has the most impact on IR, where procedures are predominantly performed in the facility setting, but practices still carry substantial indirect costs that do not shift to the hospital bill. These include:

• PACS, Vendor Neutral Archive and image storage.
• Dictation and voice recognition.
• Quality and safety, accreditation and peer learning registry participation.
• Call coverage and holiday and after-hours services.
• Tumor boards and multidisciplinary conferences.
• Prior authorization management.

These costs do not disappear when cases are performed in hospitals, yet the proposed cut assumes otherwise and directly threatens financial sustainability. While diagnostic radiology codes are exempt from this adjustment, at least for this proposed year, IR will feel the effects along with other specialties. For IR practices, particularly those in hospital-predominant and mixed-site settings, this policy threatens to significantly under-recognize practice-side overhead, undermining financial viability and patient access.

Supply Pack Pricing Risks in IR

CMS continues to update supply pack pricing, including creating new angiography packs and correcting past errors. On the surface, this seems technical. But for IR, it is pivotal.

High-cost disposables such as coils, thrombectomy catheters and stent grafts are the backbone of modern minimally invasive care. If reimbursement lags actual prices, practices will not be able to offer these services and access will shrink. Academic IR divisions may struggle to offer cutting-edge procedures and develop new therapies. Community practices may stop offering them altogether.

Without accurate, regularly updated pricing of procedure supplies, IR cannot grow to support our patients and our communities.

A Push Toward Consolidation

Individually, these cuts may look like small changes to accounting details. Taken together, they create a strong financial push toward consolidation:

• Large hospital systems can absorb cost reallocations more easily.
• National platforms are better able to negotiate device pricing at scale.
• Smaller groups face disproportionate harm and may see mergers or employment as the only path forward.

For all practices, consolidation can bring the added stress of trying to merge conflicting cultures and clearly define budgets. Regardless of practice setting, the trend is the same: policies that shrink margins incentivize greater consolidation for size and scale, but it also risks reducing access and innovation.

This is not only a problem for private practices. Academic departments depend on Medicare margins to fund teaching and research. Multispecialty groups must balance internal equity as radiology absorbs outsized cuts. Independent practices face survival questions.

The bottom line: Every radiologist, regardless of setting, is affected. This is why ACR advocacy is essential. The College has the credibility, infrastructure and expertise to make radiology’s case to CMS and needs the collective weight of the entire specialty and its members.

Next Steps

These changes will impact the entire house of radiology from diagnostic reading to imaging guided interventional procedures to medical physics and radiation oncology. ACR will continue to advocate on behalf of our specialty, our patients and the entire house of medicine. As an individual, you can stay engaged:

1. Stay informed — Work with your local hospital, department or practice leadership to understand how these changes impact you.
2. Participate — Share your experiences, data and patient stories with ACR as well as other stakeholders. Your concrete examples strengthen comment letters and other advocacy efforts and can influence policy.
3. Advocate — Support ACR’s policy work and contact your representatives to explain how these proposals threaten patients’ access.

Payment policy is not abstract and can be influenced. It drives how radiology is organized, how services are delivered and whether consolidation becomes survival or an opportunity to thrive. If we want a future where radiology remains strong across all practice models, we must act now, together.