Image by Michaił Nowa from PixabayThe American Association of Nurse Anesthesiology (AANA) is pushing back against UnitedHealthcare over changes to its reimbursement policy for certified registered nurse anesthetists (CRNAs).
Specifically, UnitedHealthcare, the nation’s largest health insurer, is cutting reimbursement by 15% for claims submitted by CRNAs when those providers are not supervised by a physician anesthesiologist. For ambulatory surgery centers (ASCs), the policy shift is an important and potentially disruptive one, as CRNAs often serve as key anesthesia providers in some facilities, particularly in rural or underserved areas.
AANA has described the move as “unlawful” and “discriminatory.”
“This is yet another attempt to discriminate against CRNAs by offering less compensation for their skills, expertise and time,” AANA President Jan Setnor, a CRNA herself, said in a statement. “All anesthesia providers are trained in and use the exact same techniques to administer anesthesia, yet no other providers face the same cut.”
UnitedHealthcare is “blatantly targeting CRNAs, based on their licensure alone,” Setnor continued.
The scope of practice for CRNAs varies by state. Some states allow CRNAs to work without anesthesiologist supervision, while others do not.
The U.S. Centers for Medicare & Medicaid Services (CMS) initially gave states the ability to opt-out of supervision requirements in 2001, with 17 states doing so. As of January 2025, that list of states expanded to at least 22 states, plus Washington, D.C.
A spokesperson from UnitedHealthcare told Ambulatory Surgery Center News that the policy changes are “designed to help ensure claims are paid accurately and fairly,” while “helping to control rising health care costs without affecting the quality of anesthesia services” for members.
“Health care affordability is one of the most pressing challenges Americans are facing today,” the spokesperson wrote in an email to ASC News. “We are committed to being a responsible steward of our customers’ and members’ health care dollars. We are updating our reimbursement approach for [CRNAs] to better align with their licensure.”
UnitedHealthcare’s policy change is targeted toward anesthesia services appended with the QZ modifier, which indicates no physician supervision, the spokesperson added.
“While CRNAs are highly trained advanced practice nurses, they are not board-certified physicians,” the spokesperson said. “Their ability to practice independently varies by state law and licensure.”
AANA is legally challenging the insurer’s move in the U.S. District Court for the Northern District of Ohio.
“At a time when the country is acutely aware of health care costs and accessibility, United is choosing to pursue a reimbursement policy that will devastate health care delivery by further impeding patient access, particularly in rural and underserved areas,” Setnor continued. “Make no mistake, this change only serves UnitedHealthcare’s profits by shifting costs to hospitals and ambulatory surgery centers under the guise of a discriminatory attack on CRNA-provided care.”
UnitedHealthcare’s anesthesia reimbursement change is effective Oct. 1, 2025. It will affect all providers except those in Arkansas, California, Colorado, Hawaii, Massachusetts, New Hampshire and Wyoming, according to AANA.
While CRNAs play a critical role for many ASCs, some operators remain hesitant to leverage their skills because of misinformation and confusion, industry experts say.
And even in opt-out states, regulators have put pressure on facilities using CRNAs independently. Speaking with ASC News in October 2024, health care attorney Rachel Carey described two such scenarios that took place in California.
“The goal should be to ensure that all patients receive safe, high-quality anesthesia care, whether it’s provided by a CRNA or an anesthesiologist,” Carey said. “But the reality is that cutting corners on staffing, particularly in anesthesia, can lead to serious compliance issues and, more importantly, adverse patient outcomes.”
CRNAs represent more than 80% of the anesthesia providers in rural areas, according to industry statistics.
As part of a 2023 white paper from Medicus Healthcare Solutions, 75% of CRNAs reported practicing without physician oversight. The same white paper emphasized how CRNAs have helped ease some of the unmet demand for anesthesiologists across the U.S., including rural areas.
“However, despite administering more than 50 million anesthetics each year, CRNAs face growing workforce shortages, supervision requirements and state-level scope-of-practice restrictions that limit their ability to expand service capacity,” the white paper explained.
The UnitedHealthcare spokesperson also noted the change was to create more uniformity with other reimbursement policies
“We are updating our reimbursement approach to reflect the licensure and scope of practice of the provider delivering care – whether an anesthesiologist or a CRNA – consistent with how other areas of health care are reimbursed,” the spokesperson said.
