In 2025, CMS finalized a 2.9% pay increase for hospital outpatient and ASC services, based on a 3.4% market update, minus a 0.5% productivity adjustment.
Several major insurance companies are following suit, also steering volume toward the outpatient setting, as studies have shown that ASCs can help to reduce costs for patients and payers alike.
Here are eight ways payers are steering volume to the ASC setting:
1. Some payers have held ASC reimbursement rates steady while lowering HOPD payments. However, some insurers also require hospitals to perform a certain volume of outpatient procedures in ASCs.
2. Minnetonka, Minn.-based UnitedHealthcare has implemented a rule that permits primary care physicians to directly refer patients for most ASC procedures but mandates preauthorizations for HOPD services.
3. UnitedHealthcare, Aetna and Medicare beneficiaries have lower copays for ASCs than HOPDs, and the California Public Employees’ Retirement System drives patients to ASCs by requiring them to pay any costs exceeding a set price.
4. Twenty-five percent of surveyed hospitals and health systems said they are expanding their ASC footprint specifically due to payer pressure. A rising trend involves commercial payers partnering with hospitals and health systems — a movement expected to accelerate in the coming years.
5. In 2022 and in 2023, insurer Aetna expanded the list of procedures that can be provided without precertification if performed in an ASC.
6. In 2022, Blue Cross and Blue Shield of Texas increased the maximum allowable standard fee schedule reimbursement for nearly 1,500 outpatient surgery services when performed at in-network ASCs. In 2023, the payer did the same with 63 additional outpatient surgery services.
7. In 2021, Empire BlueCross BlueShield in New York updated its coverage policy to drive more surgical procedures to ASCs. Empire commercial plan members now need a medical necessity review to have certain procedures performed in the HOPD setting instead of an ASC.
8. Just eight years ago, CMS and the majority of insurance companies did not reimburse for total joint replacements in the ASC setting. Now, outpatient joint replacements are common practice at ASCs nationwide.
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