ASCs are facing reimbursement pressure on several fronts this fall, from payers slow to pay arbitration awards to a proposed Medicare pay cut CMS is expected to finalize in November.
Here are five recent threats to ASC reimbursement:
1. 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 No Surprises Act independent dispute resolution awards, according to an Oct. 16 complaint reviewed by Becker’s. The providers won 1,443 awards totaling roughly $2.75 million, of which Anthem had paid about $249,800 as of Oct. 15, according to the complaint.
2. The number of provider groups receiving federal IDR decisions on ASC claims nearly doubled to 2,580 in 2025, up from 1,324 in 2024, according to an analysis from Sunlight. The data also shows how far initial payments can trail final awards: For single-level lumbar transforaminal epidural injections (CPT 64483), the median award exceeded the plan’s first payment by $13,764, and plans initially paid $0 on 22% of line items.
3. Nearly one-third of ASCs offer financial assistance in their contracts with anesthesia providers or groups, according to the Ambulatory Surgery Center Association’s third-quarter 2026 60-Second Survey, published Oct. 16. Stipend contracts remain the most common form of assistance, cited by 51% of the 307 respondents, while the use of flat subsidies fell to 15% in 2026 from 27% in 2023.
4. Centene is the latest national insurer to roll out a prior authorization gold card program, joining UnitedHealthcare and Humana. For ASCs, the catch is where the exemption lands: In most programs, the gold card belongs to the surgeon’s practice, not the surgery center. Meanwhile, CMS began a five-year demonstration requiring prior authorization for certain ASC services in 10 states in early 2026, and its WISeR model targets 17 services in six states.
5. Most non-qualifying alternative payment model physicians face a 1.68% cut to the Medicare conversion factor in 2027 under CMS’ proposed physician fee schedule. Under the separate proposed ASC payment rule, facility rates for CPT 64483 and 64493 would drop to $466.96 from $485.51.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
