The federal government’s newest price transparency rule is written for payers, but its effects could reach ASCs well before the first revised rate files post in 2027.
CMS and the Labor and Treasury departments finalized an overhaul of the transparency in coverage rules Oct. 5, revising the regulations that have required payers to post negotiated rates since 2022. The final rule cuts so-called “ghost rates,” reorganizes rate files by provider network, expands out-of-network disclosures and requires plan executives to vouch for the accuracy of the data. It takes effect Dec. 5, and most of the data requirements phase in across 2027.
The rule adds no posting requirements for surgery centers, which are not required to publish prices the way hospitals are. Hospitals operate under separate federal rules that, as of this year, require actual dollar amounts rather than estimates. What the rule changes for ASCs is the payer-side data: the files that show what insurers have negotiated with competing providers.
The most consequential change may be the removal of ghost rates, or published rates for services a provider is unlikely to be paid for given its specialty, such as heart surgery rates listed for podiatrists. In March, Georgetown University researchers found 91.8% of rates listed in transparency in coverage files across 61 insurers were ghost rates.
Under the final rule, payers will decide which rates to drop using their own internal rules but must publish those rules in a new taxonomy file, due Oct. 1, 2027. Because payers set the criteria, ASC leaders and the surgeons who operate in their centers may want to check how each payer classifies their specialties once the files post.
Payers will also post one in-network rate file for each provider network rather than one for each plan, with a network name and identifier attached to each file. The format matches how hospitals typically report their own pricing. A new utilization file, due July 1, 2028, will list providers that were paid for at least one claim. Together, the changes are designed to cut duplicate data and make the files easier to work with, which could give ASCs a clearer view of competitors’ rates heading into payer negotiations.
Out-of-network data should also become more plentiful. Payers currently report an out-of-network allowed amount only after at least 20 claims; that threshold drops to 11, and each file will cover six months of claims instead of 90 days. Files will be grouped by market type — large group, small group, individual and self-insured — and list each plan’s product type, such as HMO or PPO. For out-of-network centers, or those weighing whether to go in-network, that means more allowed-amount data to benchmark against.
The tradeoff is timeliness. In-network and out-of-network files will be updated quarterly instead of monthly, so the data will be leaner but less current.
The rule also reaches the patient side. Starting with plans beginning on or after Jan. 1, 2027, members will be able to get personalized cost-sharing estimates by phone, in addition to the online and paper options already required. For surgery centers competing with hospital outpatient departments on price, wider access to estimates could put more of those comparisons in front of patients. Regulators did, however, decline to require consumer-friendly cost summaries in the files themselves, saying the data cannot reflect an individual’s deductible or other personal cost-sharing requirements.
Whether the data is reliable enough to act on is another question. A study of 2025 files from Aetna, Cigna and UnitedHealthcare found hospital inpatient data completeness ranged from 2% to 81% across the three insurers. Payers have never been publicly fined for violating the rules, while CMS has fined 28 hospitals.
The final rule requires each file to include an attestation that the data is accurate and complete, along with the name of the plan CEO, president or senior executive who oversees it, mirroring a hospital requirement CMS began enforcing in April. The government also said it will prioritize enforcement and work to make those actions public.
More usable data won’t necessarily push prices down. The Georgetown analysis cautioned that providers and private equity firms may use the same data to maximize revenue, a reminder that every side of the negotiating table will be reading the files. Payers must post their first revised in-network and out-of-network files April 1, 2027.
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.
