Ambulatory surgery centers, or ASCs for short, are rising in popularity by offering surgical, diagnostic and preventive procedures without the need for an overnight hospital stay. Also referred to as outpatient surgery centers, same-day surgery centers or surgicenters, these facilities are becoming an attractive alternative to going to the hospital for their convenience and lower costs.
“Due to the efficiencies and cost-control measures that ASCs offer, the cost of that care is likely to be much lower than the cost of the same care in a hospital outpatient or inpatient setting,” says Bill Prentice, CEO of Ambulatory Surgery Center Association.
But how do you navigate insurance and costs of an outpatient procedure at an ASC?
[Read: What Is an Ambulatory Surgery Center, ASC?]
What Are Ambulatory Surgery Centers?
Ambulatory surgery centers are freestanding outpatient facilities that provide same-day surgical, diagnostic and preventive procedures.
In the United States, there are more than 6,300 Medicare-certified surgery centers, up from 4,000 in 2004. Because each ASC operates independently, no two ASCs are alike.
“Some ASCs provide services in only one specialty and some provide services in many different specialties,” Prentice says. “Some are run by one physician or a small health care team to serve a much larger community.”
Surgeries performed at these centers are considered “elective” procedures, which means they are not emergency procedures and can be scheduled in advance. Your physician will be able to tell you if the procedure can be provided at an ASC or needs to be done at an inpatient hospital setting.
“As a health care provider, I believe that ASCs are an important part of our health care system, and they will continue having an increasingly important role in providing care to our patients as technology allows us to do more and more procedures in the outpatient setting,” says Dr. David Weinstein, an orthopedic surgeon with the Surgical Center of the Rockies in Colorado Springs, Colorado.
[READ: How to Recover From Surgery]
Medicare Coverage of Procedures at Surgery Centers
Patients covered under Medicare can determine the cost of their care at an ambulatory surgery center by visiting Medicare’s Procedure Price Lookup Tool.
After talking with your doctor and determining the current procedural terminology (CPT) code for the procedure, you can search on the webpage to find out exactly how much Medicare will pay for the procedure.
Once you’ve met your Part B deductible, you’ll typically pay 20% of the Medicare-approved amount to both the surgical center and your doctor. While many preventive services are covered at no cost if your provider accepts it, other costs may apply. For example, polyp removal during a screening colonoscopy could mean a 15% copay. If you have a Medicare Advantage plan, you must contact them to determine your benefits and costs.
In many cases, the amount Medicare will ask patients to pay will be less than what it would cost in a hospital outpatient setting. For instance, the reimbursement for cataract removal is $341 at an ASC and $549 at a hospital. The lower cost is passed on to the patient in the form of lower co-insurance rates.
Medicare currently reimburses ASCs for providing 4,684 different procedures. It reimburses hospital outpatient departments for providing all of those procedures, plus an additional 369 more.
[Does Medicare Cover Cataract Surgery and How Much Does It Cost?]
Private Insurance Coverage of Outpatient Surgeries
Individuals with private insurance need to go directly to their insurance to find out how much they will need to pay for the procedure at an ASC. For those who qualify, health savings account (HSA) or flexible spending account (FSA) dollars can be used towards helping cover eligible expenses.
The “No Surprises Act,” which took effect January 1, 2022, was passed by Congress to address unexpected gaps in health insurance coverage that result in “surprise medical bills” when patients unknowingly obtain medical services from physicians and other providers outside their health insurance network. The measure specifically requires ASCs to give a good faith estimate in these cases, and ASCs frequently work with their patients before the day of their procedure to determine the cost of care.
Payment Plans
Another option is to look into what types of payment plans.
Third-party financing
Many doctors and facilities partner with third-party financing companies, like CareCredit, PatientFi or Wells Fargo Health Advantage. These companies may offer promotional financing options, often featuring 0% interest for a limited time, making them a popular way to cover out-of-pocket medical expenses.
However, it’s important to fully understand the terms before committing. In some cases, if the balance isn’t paid in full by the end of the promotional period, deferred interest may be applied, meaning interest is charged retroactively on the original loan amount, which can lead to a significant financial burden.
Alternatively, some companies offer fixed-interest loans with predictable monthly payments, which may be a better option for those who need a longer repayment period. These financing options are typically available for online or in-office applications, with approval based on credit score and financial history.
Directly with the ASC
Many ASCs offer their own internal payment plans, which may be more flexible than third-party options. ASCs often have more leeway in tailoring payment plans to individual patient circumstances.
ASCs might offer longer repayment periods or lower monthly payments compared to third-party lenders. They may be more willing to waive certain fees or offer discounts to patients who are committed to paying their bills within a certain timeframe.
Applying for an internal payment plan might be less complex than going through a third-party lender and there may be less paperwork with quicker approval times.
Paying Out-of-Pocket in Full
Individuals considering paying for their procedure out of pocket in full should reach out to the ASC to discuss the total cost of their care. It’s important to initiate a conversation with the ASC’s billing department to get a clear breakdown of charges and explore potential discounts.
Many centers appreciate upfront payments and may offer cost reductions, but these are often not publicly advertised — you have to ask.
If you are paying in full before your procedure, you are in a strong negotiating position. ASCs often prefer upfront payments because they avoid the administrative burden of dealing with insurance claims or delayed reimbursements. In many cases, they are willing to offer a lower price to patients who commit to paying in full.
Keep in mind, processing credit card transactions involves fees for the ASC. If you pay in cash, you eliminate this cost for them, making them more receptive to a discount.
Out-of-Pocket Fees: What to Expect
ASCs typically bill individuals for certain expenses that may or may not be covered by insurance.
The ASC will bill the individual separately for their physician’s services and should address all questions about the cost of that care with their physician’s office. Medicare currently requires all ASC charges to be filed electronically using the CMS-1500 form, with most other insurers using the UB92 form.
ASCs may charge any of the following fees:
— Anesthesia services: Individuals will receive a separate invoice for any anesthesia services, including the physician’s fee and any medications used. Address all questions regarding those services with the anesthesia group or medical professional that provided that care.
— Copayments and deductibles: ASCs will typically submit claims to the patient’s insurance provider for reimbursement. However, individuals may be responsible for copayments and deductibles.
— Facility fees: Individuals may be charged a facility fee for using ASC’s surgical rooms and facilities. This fee covers overhead costs such as rent, utilities, and administrative expenses. (See table below for list of facility services and supplies reimbursed by Medicare.)
— Out-of-network costs: If the ASC is not in your network, you may be billed for a higher amount, as out-of-network providers often charge higher rates. Always double check first to make sure the ASC is within your insurance network.
— Procedure costs: Depending on the procedure needed, an individual might be required to pay for some additional services and supplies before or after their surgery. These costs can include laboratory and pathology tests and durable medical equipment, such as crutches or leg compression pumps.
— Preoperative and post-operative care: Depending on the ASC’s policies, patients may also be billed for pre-operative consultations, tests and postoperative follow-up care.
According to ASCA, the Medicare facility fee reimbursements for ASCs include:
Are There Any Hidden Fees?
Occasionally, a surgeon will find that an additional, unexpected procedure may be needed. This may include a surgeon who finds an unexpected cancerous growth that was not detected in advance and decides to remove and biopsy it immediately rather than delay that procedure.
“When those types of additional procedures are deemed necessary, an individual and their insurance provider will be responsible for covering the cost of that additional care,” Prentice says.
Bottom Line
Ambulatory surgery centers are increasingly popular options for outpatient procedures — in large part due to their convenience and lower costs compared to traditional hospital outpatient departments.
Patients can determine costs of their outpatient procedures through Medicare tools or speaking with their private insurance.
To determine which is best for you, it’s important to work with your doctor to decide whether you are a good candidate for an outpatient procedure at an ASC based on your health status, type of procedure and risk of complications.
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Navigating Insurance and Costs for Ambulatory Surgery: A Comprehensive Guide on How to Pay originally appeared on usnews.com
Update 03/06/25: This story was published at an earlier date and has been updated with new information.
