Ambulatory surgical centers negotiate their own rates with insurance companies, and those rates vary by location, procedure, and payer
Unlike hospitals, which often have standardized rate-setting frameworks, ambulatory surgical centers (ASCs) set payment rates through direct negotiation with each insurance company. There is no single national rate table. An ASC in one state may receive $3,000 for the same procedure that an ASC in another state receives $2,200 for—and the same ASC may have different rates with Blue Cross than with Aetna.
Medicare does publish a national rate schedule for ASCs, but commercial insurance companies (Aetna, Cigna, UnitedHealth, regional Blues plans) each negotiate independently. This means the bill you receive and what your insurance pays depends on the specific contract between your ASC and your specific plan.
If you are uninsured or paying out of pocket, the ASC sets the price directly. Many ASCs publish their cash rates upfront; others quote you when you call. These rates are often lower than what they bill insurance, because they avoid the administrative cost of claims processing.
Key Takeaways
- Medicare sets a national ASC payment rate for each procedure code, adjusted annually and by geographic region, but commercial insurers negotiate their own rates with each center.
- An ASC's negotiated rate with one insurance company has no bearing on what it charges another company or what it charges uninsured patients.
- ASCs typically charge less for cash pay than they bill to insurance, because they avoid claims processing and collection delays.
- The procedure code, the ASC's location, and the complexity of the case all affect what rate an ASC negotiates with a payer.
- You can ask your ASC for their cash price or their contracted rate with your insurance before your procedure.
How Medicare sets the ASC payment baseline
Medicare publishes an Ambulatory Surgical Center Payment System (ASCPS) rate schedule every year. The rate for each procedure is tied to a Current Procedural Terminology (CPT) code—the five-digit code that describes what was done during surgery.
Medicare's ASC rate for a given procedure is typically 40 to 50 percent of what it would pay a hospital outpatient department for the same procedure. This is by design: ASCs have lower overhead than hospitals (no emergency room, no inpatient beds, no 24-hour staffing), so Medicare pays them less.
The base rate is adjusted by a geographic practice cost index (GPCI), which means the same procedure pays more in New York City than in rural Montana. Medicare also adjusts for inflation annually. The 2024 rates are different from the 2023 rates, and next year's will shift again.
An ASC does not have to accept Medicare rates—it can opt out of Medicare entirely. But most do accept them, because Medicare patients represent a steady volume of business.
How commercial insurance companies negotiate rates
When a commercial insurance company (like Aetna or Cigna) contracts with an ASC, the two sides negotiate a fee schedule. The insurance company typically uses Medicare's rate as a starting point—often proposing to pay Medicare's rate plus a percentage, or sometimes less than Medicare pays.
The ASC's negotiating power depends on several factors: whether it is the only ASC in the area offering a particular specialty (orthopedic surgery, ophthalmology, gastroenterology), how many of the insurance company's members live nearby, and whether the ASC has a reputation for high quality or low complication rates.
An ASC in a competitive market with five other surgical centers nearby will likely accept lower rates than an ASC that is the only option for 50 miles. A high-volume ASC that performs hundreds of cataract surgeries per year may negotiate better rates than a smaller center.
Once a rate is negotiated, it is locked into the contract for a set period—usually one to three years. When the contract renews, both sides can renegotiate. If the ASC and insurer cannot agree on new rates, the contract lapses and the ASC may no longer be in-network for that plan.
What factors change the rate for your specific procedure
Even within a single ASC and a single insurance company, the rate can vary based on the complexity of your case. Most ASCs use a relative value unit (RVU) system, which assigns a complexity score to each procedure.
A straightforward cataract removal might be assigned 1.0 RVU. A cataract removal with complications, or combined with another procedure, might be 1.5 or 2.0 RVU. The ASC multiplies the RVU by a conversion factor (a dollar amount set in the contract) to arrive at the final payment.
The ASC's location within a state also matters. An ASC in a high-cost urban area may have negotiated higher rates than an identical ASC in a lower-cost region, because the urban center's overhead is higher.
Facility fees (the charge for using the operating room, equipment, and staff) are separate from the surgeon's fee. The ASC bills the facility fee; the surgeon bills separately. Your insurance company may have different negotiated rates for each component.
How uninsured and cash-pay rates are set
An ASC that is not billing insurance sets its own cash price. Many ASCs publish these rates on their website or in a price list. Others require you to call for a quote.
Cash rates are often 30 to 50 percent lower than the ASC's billed charge to insurance, because the ASC avoids the cost of claims processing, billing staff, and collection delays. If you pay in full at the time of service, you may receive an additional discount.
Some ASCs offer payment plans for uninsured patients, allowing you to pay over several months with no interest. Others require payment upfront or at the time of your pre-op visit.
If you are uninsured, call the ASC's billing department and ask for the cash price before your procedure. Get it in writing. You can also ask whether they offer financial assistance programs or whether they will negotiate the price based on your income.
Why your bill may not match what insurance paid
The amount the ASC bills your insurance is often higher than the negotiated rate. This is normal. The ASC sends a claim to your insurance company; the insurance company pays the negotiated rate; the ASC writes off the difference as a contractual adjustment.
You are responsible for your copay, coinsurance, or deductible—not for the difference between the billed amount and the negotiated rate. If you receive a bill for that difference, contact your insurance company and the ASC's billing department to resolve it.
If the ASC is out of network with your insurance, you may be billed at a higher rate, and your insurance may pay less or nothing at all. This is why it is important to confirm that your ASC is in-network before your procedure.
How to find out what your procedure will cost
Call your ASC's billing department and provide your insurance information. Ask them to tell you: the procedure code (CPT code), the negotiated rate with your insurance, your copay or coinsurance amount, and whether your deductible applies.
Then call your insurance company and verify the same information. Insurance companies sometimes have different rates in their system than what the ASC quotes, so checking both sides protects you.
If you are uninsured, ask the ASC for a written cash price quote. Some ASCs will also provide an estimate of what Medicare or a specific insurance company would pay, which can help you understand the range.
If the cost is higher than you expected, ask whether the ASC offers a discount for cash pay, a payment plan, or financial assistance. Some centers will negotiate if you ask.
Frequently Asked Questions
Can an ASC charge me the difference between what they billed insurance and what insurance paid?
No, not if the ASC is in-network with your insurance. The difference is a contractual adjustment that the ASC must write off. If you receive a bill for this difference, contact your insurance company and the ASC's billing department—this is a billing error.
Why does the same procedure cost different amounts at different ASCs?
Each ASC negotiates its own rates with each insurance company. Rates depend on the ASC's location, volume, specialty, and negotiating power. An ASC in a competitive market may charge less than one with no nearby competitors.
Does Medicare pay ASCs the same amount as hospitals for the same procedure?
No. Medicare typically pays ASCs 40 to 50 percent of what it pays hospital outpatient departments for the same procedure, because ASCs have lower overhead. The exact percentage varies by procedure.
What if my ASC is out of network with my insurance?
Out-of-network ASCs can charge whatever they want, and your insurance may pay less or nothing. You could be responsible for the full bill. Confirm your ASC is in-network before scheduling, or ask your insurance company whether they will cover an out-of-network facility.
Can I negotiate the price if I am paying cash?
Yes. Many ASCs will negotiate cash prices, offer discounts for upfront payment, or set up payment plans. Call the billing department and ask what options are available. Get any agreed price in writing before your procedure.