Regulators cut the cost of surprise-billing arbitration by 87%, at least four states tightened the rules on private equity deals, and the Department of Justice ran the largest healthcare fraud sweep in its history — all since January.
Here are 25 legal and regulatory updates from the past 10 months that ASC leaders should know, grouped by topic.
No Surprises Act
1. Federal regulators finalized the long-awaited IDR operations rule. HHS, the departments of Labor and Treasury, and the Office of Personnel Management issued the Federal Independent Dispute Resolution Operations final rule May 28, the largest update to the arbitration process since it launched in 2022. The rule took effect Aug. 3, with many provisions phasing in through 2027. It does not change who the law covers or how the qualifying payment amount is calculated.
2. The IDR administrative fee fell from $115 to $15. The per-party, per-dispute fee dropped by more than 85% for disputes initiated on or after June 11, regardless of the amount in dispute or whether the dispute is ultimately ruled eligible.
3. Batching expands to 50 line items Nov. 1. Disputes whose open negotiation periods begin on or after Nov. 1 can batch up to 50 line items, up from 25. The rule also broadens which anesthesiology, radiology, pathology and lab claims can be batched together. Standardized claim adjustment reason codes and remittance advice remark codes become mandatory for payers in 2027, with the specific codes to come in later guidance.
4. Payers must register, and open negotiation moves onto the federal portal. Plans and issuers must now register in a new federal IDR registry, and the 30-day open negotiation period runs through the federal IDR portal rather than proprietary payer portals. Certified IDR entities have five business days to rule on eligibility. A new IDR gateway platform for filing and tracking disputes is set to launch this year.
5. Physicians are pushing Congress to put teeth behind IDR awards. The American Medical Association, 50 state medical societies and 46 healthcare groups backed the No Surprises Act Enforcement Act (H.R. 4710/S. 2420) in a May 11 letter. The bill would penalize plans that miss the 30-day deadline to pay IDR awards and give regulators explicit authority to enforce decisions. It remains in committee.
6. A $22.4 billion price tag reignited the cost debate. Georgetown University researchers estimated in an Aug. 26 Health Affairs analysis that the IDR process cost $22.4 billion from 2022 through 2025, including $15.6 billion in awards above in-network rates. Costs hit $16.6 billion in 2025 alone, nearly 3.5 times the 2024 total, as dispute volume rose 77%. Physician groups countered that qualifying payment amounts are set too low, pointing to physicians’ high win rates in arbitration.
7. Providers are taking unpaid awards to court. Brentwood, Tenn.-based SpecialtyCare and two affiliated physician groups sued two Anthem health plans, alleging the insurers failed to pay about $2.5 million in IDR awards.
Private equity
At least 79 bills addressing private equity and investor-backed ownership in healthcare were introduced across 26 states in 2026, according to a May analysis in The American Journal of Managed Care. Seven states passed new restrictions or reporting requirements in 2025, up from one in 2024.
8. California’s two PE laws took effect Jan. 1. SB 351 bars private equity groups and hedge funds — and the MSOs they own — from interfering with physicians’ clinical judgment, including control over medical records, hiring, payer contracting, and billing and coding. AB 1415 requires PE groups, hedge funds and management service organizations to notify the Office of Health Care Affordability at least 90 days before closing material-change transactions.
9. Washington state widened its transaction notice law. Gov. Bob Ferguson signed HB 2548 on March 25, effective June 11, expanding the types of deals that trigger the state’s 60-day advance notice to the attorney general. A broader corporate practice of medicine bill, SB 5387, did not pass — the state’s second failed attempt — though lawmakers are revisiting it with Oregon as the model.
10. Connecticut became the first state to ban hospital sale-leasebacks. Gov. Ned Lamont signed SB 196 May 27. The law bars PE entities from controlling hospital governance and operations, requires hospitals to certify annually that no such control exists, and prohibits sale-leaseback deals beginning July 2027. It followed the collapse of Prospect Medical Holdings, which led to three Connecticut hospital closures.
11. Vermont limited PE control over clinical decisions. Gov. Phil Scott signed H.583 June 15, barring PE firms, hedge funds and the entities they control, including MSOs, from directing medical decisions. Healthcare companies must also disclose their ownership structures and investor relationships. The final law is narrower than the original draft, which would have shut PE out of the state’s healthcare market.
12. Illinois made its transaction notice law permanent and named PE explicitly. Gov. JB Pritzker signed HB 5000 Aug. 7. The law covers any deal “involving” healthcare facilities or provider organizations, including those by PE firms that own them indirectly, and removes the Jan. 1, 2027, sunset. PE firms with at least $10 million in annual revenue from Illinois patients must give the attorney general 30 days’ notice before closing.
13. Oregon’s corporate practice of medicine law survived its first major test. SB 951, signed in June 2025, requires physicians to hold at least 51% ownership in most practices and is widely considered the nation’s strictest such law. Local physicians invoked it to challenge PeaceHealth’s plan to replace its 35-year ED staffing partner with ApolloMD.
14. Sen. Chris Murphy, D-Conn., introduced the Take Back Our Hospital Act. The March 12 Senate bill would target hospital sale-leasebacks and PE ownership of nursing homes nationally. It has not advanced to a vote.
15. A bipartisan bill would ban the corporate practice of medicine nationwide. The Stop Corporate Takeovers of Physicians Act, introduced Sept. 16 and modeled on Oregon’s law, would bar entities not majority-owned and controlled by physicians or advanced practice providers from practicing medicine, with a private right of action. Attorneys at law firm Foley & Lardner said it would upend the PC-MSO model PE sponsors use to invest in practices.
Federal fraud enforcement
16. False Claims Act recoveries hit a record $6.8 billion. The Justice Department recovered $6.8 billion under the False Claims Act in fiscal 2025, the highest annual total in the law’s history and more than double the 10-year average. Becker’s tracked six Stark law settlements over the past year spanning eye care, anesthesiology, pain management and hospital-physician compensation.
17. The 2026 National Health Care Fraud Takedown was the largest in Justice Department history. Announced June 23, the sweep charged 455 defendants, including 90 physicians and other licensed professionals, in schemes involving more than $6.5 billion in false claims. Cases spanned 56 federal districts, and 50 state Medicaid Fraud Control Units took part. CMS suspended 1,079 providers and revoked billing privileges for 1,403.
18. Medicaid and wound care drew outsized attention in the takedown. The Justice Department charged 295 defendants tied to more than $518 million in false Medicaid claims, its largest Medicaid action on record. Charges also included 11 defendants in wound allograft schemes and a Florida cardiovascular practice medical director in an $89 million case involving unnecessary cardiac testing on student athletes.
20. ASCs now have one place to report potential criminal fraud — and one costly misstep to avoid. The Justice Department’s National Fraud Enforcement Division and HHS-OIG issued a policy Oct. 15 that lets healthcare companies self-disclose potential criminal conduct to the Fraud Division alone and still earn credit under both the Justice Department’s Corporate Enforcement Policy and HHS-OIG’s Health Care Fraud Self-Disclosure Protocol. HHS-OIG also updated its protocol to cover only civil and administrative conduct. An ASC that discloses only to HHS-OIG generally will not qualify for a Justice Department declination, so the agencies advise bringing potentially criminal conduct, such as kickbacks or billing for medically unnecessary services, to the Fraud Division first.
Certificate of need
20. Federal rural health money is pushing states to loosen CON. Seventeen states pledged legislative or regulatory CON reforms in their applications for the $50 billion Rural Health Transformation Program created by HR 1. CMS scored states partly on their CON policies, and states that fail to follow through risk having grant money clawed back.
21. Maine exempted most ASCs from CON review. LD 1890 became law March 31 without the governor’s signature. It also raised the capital expenditure threshold for CON review from $3 million to $7.5 million and indexes future increases to inflation. The state Senate rejected a separate bill that would have extended CON review to PE-backed facility sales.
22. Tennessee will end CON for most acute care hospitals by 2030. Lawmakers passed SB 1369 April 16, replacing CON with a licensure process that requires hospitals to treat Medicaid patients and provide charity care. CON requirements for freestanding EDs and cardiac cath facilities end in 2028.
23. Iowa raised its CON thresholds. Gov. Kim Reynolds signed House File 2635 in May, a health reform package that raises the capital expenditure and equipment thresholds that trigger CON review.
24. Other states made narrower moves. The Virginia General Assembly defeated two bills that would have created CON exceptions for independent outpatient facilities and ASCs, but Gov. Abigail Spanberger signed HB 1337 April 13 to expedite review of certain projects. Nebraska extended how long a CON approval stays valid from one year to three.
25. North Carolina’s CON law survived a constitutional challenge. A trial court upheld the law Dec. 12, 2025, rejecting an ophthalmologist’s years-long claim that it creates monopolies for incumbents. ASCs in counties with more than 125,000 residents remain exempt from CON under an interim policy in place since Nov. 1, 2023.
The through line: more paperwork and longer timelines for investor-backed deals, cheaper access to arbitration, and fewer regulatory gates for new ASCs in a growing number of states. Leaders planning transactions or new sites in 2027 should build those notice periods and CON changes into their timelines now.
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