Field Notes from ASCA 2026: An Operator's Wishlist, How to Negotiate Payer Contracts, and What CMS Is Signaling for 2027

ASCA + SAMBA 2026 ran May 13 through 16 at the Walter E. Washington Convention Center. The agenda had the usual mix of clinical, operational, and quality content. What made the week distinctive was not on the program. It was the room composition, the federal presence, and the questions operators were asking outside the session halls, which together draw a fairly clear line on where the ASC revenue cycle is heading over the next twenty-four months.

1. CMS showed up, which means the rate conversation is live

The fireside chat with Dr. Mehmet Oz, the current CMS Administrator, was the most-promoted session on the Thursday program. The Administrator does not show up at a specialty trade meeting unless the agency wants the audience to receive a signal. For ASCs, the signals worth tracking are three.

First, the Hospital Outpatient Prospective Payment System and ASC payment proposed rule is the annual mechanism by which CMS sets Medicare ASC rates and the covered procedures list. The ASC industry has spent more than a decade arguing for site-neutral payment, payment parity with HOPDs for the same procedures done in the same way, and a faster pace on additions to the ASC-payable list. The presence of the Administrator in a room of ASC operators is the kind of stage-setting an agency does before it moves on those topics in the next rule cycle.

Second, the ASC Quality Reporting Program is the lever CMS uses to attach a 2.0 percent payment penalty to centers that do not submit quality data. Operators are increasingly being asked to report measures that require granular case-level data the average ASC's billing and clinical systems do not natively link. The reporting burden is a function of how disconnected the chart, the schedule, and the claim are inside most centers, and CMS has consistently used quality reporting as a forcing function on data infrastructure.

Third, prior authorization. CMS finalized the Interoperability and Prior Authorization rule in January 2024, which requires impacted payers to send prior authorization decisions within seventy-two hours for urgent requests and seven days for non-urgent ones, and to report aggregate metrics on denials. The compliance date for the API requirements is January 2027. ASCs are not the direct beneficiaries of that rule (it applies to payers), but the data transparency it generates is what will let operators benchmark their prior auth burden against the rest of the market for the first time. CMS sending the Administrator into a room of ASC operators thirteen months out from that compliance date is a calendar choice.

2. The roll-up is now the room

The published attendee list and the floor traffic this year skewed heavily toward platform operators and corporate ASC groups. AMSURG, SCA Health (Optum), USPI (Tenet), Compass Surgical Partners, Atlas Healthcare Partners, Advocate Health, and CHS all had multiple senior operators in attendance. The independent single-site ASC is still represented, especially through the state association track, but the directors of operations, finance, and contracting from the platform side outnumbered them in the breakout sessions on payer relations and revenue cycle.

This matters because the corporate ASC operator buys infrastructure differently from the independent center. The platform operator has a billing organization, a contracting team, a payer relations function, and a finance team that benchmarks every center against the rest of the portfolio. When that operator looks at a revenue cycle problem, the question is whether the problem can be solved at the portfolio layer, where one fix lifts twenty or fifty or two hundred centers at once, rather than at the single-center layer where the fix only pays back across a few thousand cases a year.

That preference reshapes what the next generation of ASC revenue cycle infrastructure has to do. It has to be auditable end-to-end so the platform finance team can roll cases up by payer, procedure, and surgeon without rebuilding the data layer in a spreadsheet. It has to handle the contracted-rate variability across a portfolio that mixes Medicare, commercial PPOs, Medicare Advantage, workers' comp, and increasingly direct-to-employer arrangements. And it has to address the operational asymmetry that the bigger the operator gets, the harder it becomes to staff a denials team that actually understands the procedure-level documentation requirements for orthopedics, GI, ophthalmology, pain, and cardiology at once.

Independent centers will continue to anchor the ASCA membership. But the buying decisions that move the market are increasingly made by platform operators, and those operators are no longer differentiating on "we have a great biller." They are differentiating on whether they can predict, at the time of scheduling, whether a case will get paid and how much will need to be reworked.

3. Prior auth is the bottleneck operators actually talk about

The published sessions on revenue cycle covered the expected ground: clean claim rate, days in AR, denial categories, and the perennial debate over outsourced versus in-house billing. The conversation in the hallway, in operator-to-operator catch-ups, and in the questions audience members brought to the microphone was narrower than that. It was overwhelmingly about prior authorization.

The reason is structural. A denial after the case has been performed is recoverable through appeals, payer escalation, and persistence. It is annoying, expensive, and slow, but the dollars are usually retrievable. A prior authorization that never gets to "approved" before the surgery date is a different problem. The case either gets rescheduled (which costs the center a slot, costs the surgeon a day, and erodes patient confidence), or it gets performed at financial risk to the center, or it gets cancelled. None of those outcomes are recoverable downstream.

The honest read of the floor is that ASC operators are not asking for a better way to chase denials. They are asking for a way to never lose the case in the first place. That is a different operational problem, and it sits earlier in the workflow than where most ASC revenue cycle tooling is pointed today. The piece of the stack that has to change is the predictive layer that sits between scheduling and the payer's authorization decision: the part that knows, before the case is booked, whether the medical necessity documentation, the CPT and ICD-10 alignment, the site-of-service rules, and the payer-specific clinical criteria are all going to clear on the first submission.

United Healthcare's announcement earlier this year that it would reduce prior authorization requirements by roughly 30 percent across certain commercial lines was the news everyone in the room had already absorbed. It was treated less as relief and more as a directional signal. The remaining 70 percent is where most of the operator pain still lives, and the reductions on the other side were skewed toward lower-acuity procedures that were not the bottleneck. The structural answer is operator-side automation that compresses the time and friction in the part of the workflow operators still own.

What this means for the next twelve months

The ASC revenue cycle is moving in the same direction the rest of healthcare's purchasing infrastructure is moving, which is toward operator ownership of the data, the rules, and the audit. The center that succeeds over the next twelve to twenty-four months has a few traits in common.

It has a clean operational view of the case from the moment it is scheduled, with documentation completeness, payer-specific authorization status, and contracted-rate visibility surfaced before the patient arrives. It has a denials function that closes the loop on prior auth failures into the documentation step so the same mistake does not happen twice. It has portfolio-level reporting if it is part of a platform, and it has access to the same caliber of analytics if it is independent and part of a state association or coalition. It has a payer contracting motion that benchmarks rates against the platform comps in its market, because the rates are no longer opaque the way they were ten years ago.

The infrastructure to support all of that is being built right now. The operators we spoke with in DC are evaluating it actively. The ASC revenue cycle is going to get rebuilt around the workflow that actually matters. The open question is which centers do it first.

Exactrx is building the operator-side layer of that infrastructure. If you are an ASC operator who wants to compare notes on what we saw on the floor and what we are seeing in the data across centers we work with, the line is open at partnerships@exactrx.ai.