AA guaranteed billing by A$A designed economic necessity, CRNA supervision billing by CRNA job choice based mostly on geography, HUGE difference. No guarantee exists for future government or third party payer reimbursement for MDA supervision of CRNAs. The opt out has literally freaked the A$A completely out. The opt out is the reason the A$A must insure BY LAW that the AA will not touch a patient without an MDA. Failure to acknowledge these facts do not change them.