Home Specialities Ambulatory Surgery Centers
Multi-specialty ASC
GI · ortho · ophth · pain · ENT
ASC-certified coders
APC & contract review
20–50 payer contracts
each with its own rules
Underpayment recovery
on claims marked paid
Three fee schedules. You're on the one payers misread.
The same procedure can pay three different ways depending on where it is performed, and payer adjudication systems are usually built around the first two. Yours is the exception they get wrong.
Hospital outpatient (OPPS)
Hospital outpatient departments are paid under a different fee schedule, with different packaging rules and different rates than an ASC.
Physician office (PFS)
Payer systems built around hospital and physician office logic often get ASC payment wrong, usually in the payer’s favor.
ASC Fee Schedule (yours)
APCs, status indicators, and packaging rules unique to surgery centers. Payer systems built around hospital and physician office logic often get ASC payment wrong, usually in the payer’s favor.
The leak is not in cancellations. It is in the deposit.
Case cancellations, prior auth, and A/R days get the attention. They're the loud problems. The expensive loss is the case that went smoothly, cleared the payer, posted a few points below your contracted APC rate, and was never reviewed again.
Across the 26 ASC revenue cycles we've analyzed, an average of 4–8% of gross revenue is withheld this way. For a $12M multi-specialty center, that can mean USD 480K to USD 960K per year in quiet underpayments across payer contracts.
See it on your casesWhat 4–8% looks like on a $12M ASC
The 4–8% range reflects OneMed's analysis of 26 ASC revenue cycles; the dollar figures apply that range to a $12M example center. Your actual exposure depends on payer mix, case mix, and specialty concentration.
Five fee-schedule rules payers bend in their own favor.
Each maps to a rule in the ASC Fee Schedule that payer systems apply in the way that pays you least. These are the patterns we recover most often.
MPPR misapplication
For multi-procedure sessions, the primary procedure should usually pay at 100 percent and secondary procedures at 50 percent, with specific exceptions. Payers reduce the primary instead, apply MPPR to exempt codes, or use the wrong percentage.
Device-credit misapplication
When a manufacturer credit reduces an implant's cost, the APC payment drops proportionally. Payers apply that reduction even when no credit was received, at the wrong percentage, or on exempt procedures.
APC / status-indicator misclassification
Every service carries an APC and a status indicator that sets whether it's payable, packaged, or separate. Payers assign the wrong APC, treat a separately-payable service as packaged ($0), or lag CMS updates and pay stale rates.
Bilateral modifier shortfall
Bilateral cases (cataracts, knee scopes, carpal tunnel, joint injections) should pay 150% of the unilateral rate with Modifier 50 or RT/LT lines. Payers pay them flat, reduce to 50%, or deny the second side.
Office-based downgrade
Payers maintain lists of procedures they consider office-based and may deny them or pay them 30 to 60 percent below the ASC rate, even when CMS has approved the procedure for the ASC setting and the payer’s list is outdated.
Your leak hides in your weakest specialty line.
Payers underpay hardest where your billing is thinnest. These five underpayment types usually concentrate across a multi-specialty ASC book. Find the weakest line, and you will usually find most of the money.
| Specialty line | MPPR | Device credit | APC / status | Bilateral | Office-based |
|---|---|---|---|---|---|
| Orthopaedics | |||||
| GI / endoscopy | |||||
| Ophthalmology | |||||
| Pain management | |||||
| ENT & plastics |
● Primary exposure, secondary exposure, and lower exposure are based on concentration patterns from OneMed ASC audits. Your actual mix depends on case volume, payers, and contracts.
The MPPR rule is public. Watch what happens when it's applied backwards.
Multiple Procedure Payment Reduction pays the primary procedure at 100% and each secondary at 50%. That's the rule. Payer systems sometimes reduce the higher-value primary procedure instead of the secondary procedure, cutting the largest code in half.
The rule is public; you can check it against your own multi-procedure remits. Payer systems sometimes reduce the higher-value primary procedure instead of the secondary procedure, cutting the largest code in half.
See it on your own casesReduction applied to the wrong line
Based on a $6,000 primary and $1,800 secondary. MPPR rules, where the primary pays 100 percent and the secondary pays 50 percent, are standard. The dollar amounts are illustrative and should be confirmed against your contracted APC rates. Actual exposure depends on case mix and volume.
A small team can't out-audit 50 payer contracts
The problem is not effort. It is structure. ASC billing runs lean, and the contract complexity on the other side is enormous.
No contract-level APC verification
Confirming a claim paid isn't confirming it paid your contracted APC. Checking each case against the fee schedule, MPPR rules, and bilateral terms is impossible by hand at volume.
A 2–5 person team, every specialty
Most ASC billing teams are small and cover GI, orthopedics, ophthalmology, pain, and ENT at the same time. Payers tend to underpay most heavily in the service lines where the team has the least depth.
Timely filing runs out
Underpayment appeals have filing windows, often 90–365 days. Unspotted, the recovery opportunity is permanently lost.
We reconcile every case to your ASC fee schedule, line by line.
ASC-certified coders work inside your existing practice management system with no EHR change and no disruption. They review payments against the APC rates, MPPR rules, device-credit terms, and contract provisions that apply to your center.
ClearView operational visibility
ASC-certified coders work inside your existing practice management system with no EHR change and no disruption. They review payments against the APC rates, MPPR rules, device-credit terms, and contract provisions that apply to your center.
Expert clinical chart audit
Flagged cases route to our ASC-certified coders, who work inside your system to read the operative reports, confirm the procedures and implants, and review the MPPR and device-credit application.
Targeted clinical appeal
We draft documentation-backed appeals with the operative notes and contract details needed to support the correct facility payment.
Payer pattern mapping
We track which payers misapply MPPR on your ortho cases or downgrade your office-based procedures, and pursue systematic corrections and contract fixes.
The 2026 OneMed ASC Revenue Leak Index.
These are pooled, anonymized results from every ambulatory surgery center revenue cycle we audited over the last 18 months. The pattern is shown in aggregate.
26
ASC revenue cycles audited
94,000+
claims audited
$2.97M
recovered for clients
90.5%
recovery rate on appeals
Of that $2.97M, here's where it had been hiding. The facility rules payers get wrong most are the ones with the biggest dollar swing per case.
| Underpayment pattern | Share of recovered value |
|---|---|
| MPPR misapplications | 32% |
| Device-credit misapplications | 24% |
| APC / status-indicator misclassifications | 19% |
| Bilateral modifier shortfalls | 16% |
| Office-based procedure downgrades | 9% |
Aggregated across OneMed ASC underpayment audits over the trailing 18 months ($3.28M identified, $2.97M recovered). Individual results vary by payer, documentation, and contract terms.