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 pays three different ways depending on where it's done — and payer adjudication systems are built mostly around the first two. Yours is the exception they get wrong.
Hospital outpatient (OPPS)
How a hospital's outpatient department is paid — a different fee schedule, different packaging, different rates than yours.
Physician office (PFS)
How the same procedure pays in a doctor's office under the Physician Fee Schedule — again, not your rates.
ASC Fee Schedule (yours)
APCs, status indicators, and packaging rules unique to surgery centers. Payer systems built around the first two get this one wrong — in their favor.
The leak isn't in cancellations — it's in the deposit.
Case cancellations, prior auth, and A/R days get the attention. They're the loud problems. The expensive one is the case that went smoothly, cleared the payer, and posted a few points under your contracted APC rate — and never got looked at again.
Across the 26 ASC revenue cycles we've analyzed, an average of 4–8% of gross revenue is withheld this way. On a $12M multi-specialty center, that's $480K–$960K a year — quietly absorbed, contract after contract.
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
On multi-procedure sessions, the primary should pay 100% and secondaries 50% — 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 keep lists of procedures they consider office-based and deny or pay them 30–60% below the ASC rate — even when CMS has approved them for the ASC setting and the payer's list is years out of date.
Your leak hides in your weakest specialty line.
Payers underpay hardest where your billing is thinnest. Here's how the five underpayments typically concentrate across a multi-specialty book — find your softest line and you've found 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 · — lower. Concentration patterns from OneMed ASC audits; your own 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. But payer systems sometimes reduce the higher-value primary instead of the secondary — halving your biggest code.
The rule is public; you can check it against your own multi-procedure remits. On a high-value ortho or pain case, one backwards reduction is four figures — every time it happens.
See it on your own casesReduction applied to the wrong line
Based on a $6,000 primary and $1,800 secondary. MPPR (primary 100% / secondary 50%) is a standard rule; the dollar amounts are illustrative — confirm against your contracted APC rates. Actual exposure depends on case mix and volume.
A small team can't out-audit 50 payer contracts
The gap isn't effort — it's structural. 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, ortho, ophthalmology, pain, and ENT at once — payers underpay hardest on whichever line the team is thinnest in.
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 working inside your existing practice-management system — no EHR change, no disruption — against the APC rates, MPPR rules, and device-credit terms your contracts actually specify.
ClearView operational visibility
Our ClearView dashboard gives leadership real-time visibility — flagging when a case paid at $4,200 against a $6,800 contracted APC, or a bilateral paid at the unilateral rate — without changing how your staff logs in.
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 a documentation-backed appeal — the exact operative and contractual detail that supports 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.
Pooled, anonymized results from every ambulatory surgery center revenue cycle we audited over the last 18 months — the pattern, 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.