The Service Line
CMS just proposed adding roughly 618 new procedures to the list Medicare will pay ambulatory surgery centers (ASCs) to perform, the biggest single-year expansion of the ASC growth pipeline in years, while simultaneously choking off the pathway new devices use to get paid extra for using it. On July 7, 2026, the Centers for Medicare and Medicaid Services (CMS) published its Calendar Year (CY) 2027 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment System proposed rule, covering payment for roughly 6,400 ASCs nationally. The rule proposes adding about 618 surgical codes to the ASC Covered Procedures List (CPL) and removing an additional 637 services from the Inpatient Only (IPO) list, on top of the roughly 285 procedures already phased off that list for CY2026, with CMS still targeting full IPO list elimination by January 1, 2029. ASC payment rates would rise 2.4 percent overall, lifting total estimated CY2027 ASC payments to about $9.9 billion, a $520 million increase over CY2026. The catch: starting October 1, 2026, CMS proposes eliminating the alternative device pass-through pathway entirely, requiring every new applicant to clear the tougher “substantial clinical improvement” standard, a change that will slow how fast novel devices reach device-intensive ASC reimbursement. Comments close August 31, 2026. Confidence: High on the published figures, Medium on whether the code counts and the device pass-through change survive to the final rule expected around November. Sources: Calendar Year 2027 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Proposed Rule, CMS, CMS Proposes Major CY 2027 OPPS/ASC Changes Targeting 340B Payments, Site-Neutral Policy, IPO List Phase-Out, and ASC Expansion, Applied Policy.
Reimbursement
A Senate companion just landed for the bill ASC owners have chased since 2021: peg ASC payment updates to the same inflation index hospitals get, instead of a smaller one. On July 14, 2026, Senators Bill Cassidy (Republican of Louisiana) and Richard Blumenthal (Democrat of Connecticut) introduced the Outpatient Surgery Access Act of 2026 (S.4963), referred to the Senate Finance Committee, mirroring the House version (H.R.8091) that Representatives Beth Van Duyne (Republican of Texas) and John Larson (Democrat of Connecticut) introduced March 31, 2026. The bill would permanently switch ASC payment updates from the Consumer Price Index for All Urban Consumers to the hospital market basket index, and would eliminate a budget-neutrality adjustment that the Ambulatory Surgery Center Association (ASCA) says has suppressed ASC rates for years. ASCA has endorsed both versions; the group cites a KNG Health Consulting analysis projecting $73.4 billion in Medicare savings from 2019 to 2028 as procedures migrate to ASCs. Nearly identical bills have circulated in Congress since 2021 without passing. Confidence: Medium on the mechanics, Low on passage this Congress given the bill’s history and competing floor priorities. Sources: H.R.8091, Outpatient Surgery Access Act of 2026, Congress.gov, S.4963, Outpatient Surgery Access Act of 2026, Congress.gov, ASCA Supports the Introduction of the Outpatient Surgery Access Act of 2026, ASCA.
Enforcement
The Department of Justice is criminally prosecuting a hospital, not just a surgeon, over medically unnecessary operations, a rare enforcement posture every surgical facility operator should notice. Chesapeake Regional Medical Center in Virginia was indicted January 8, 2025 on charges of healthcare fraud and conspiracy to defraud the United States, over unnecessary and misclassified surgical procedures, including hysterectomies, performed by former OB-GYN Javaid Perwaiz between 2010 and 2019, for which the hospital collected an estimated $18.5 million in reimbursement; Perwaiz himself was convicted on 52 counts in 2020 and sentenced to 59 years. The hospital has pleaded not guilty, and as of a July 14, 2026 update no trial date had been set, but healthcare attorneys note a conviction would likely trigger Medicare and Medicaid exclusion, which would functionally end the hospital’s ability to operate. DOJ’s newly formed National Fraud Enforcement Division, led by Assistant Attorney General Colin McDonald under a January 2026 executive order, has signaled continued emphasis on large-scale, coordinated prosecutions. Confidence: High on the case facts, Medium on how far the DOJ’s facility-level charging posture spreads to ASC-owned entities specifically. Sources: Chesapeake Hospital Indicted for Healthcare Fraud Involving Unnecessary Surgical Procedures, Department of Justice, Chesapeake Regional Faces Fraud Charges. A Conviction Could Put the Hospital’s Future at Risk, WHRO.
Who’s Buying
Ascension closed its $3.9 billion purchase of AmSurg after the Federal Trade Commission forced it to sell off seven surgery centers, instantly making a nonprofit Catholic health system the country’s third-largest ASC platform. Ascension closed the acquisition June 4, 2026, days after reaching an FTC consent agreement requiring divestiture of seven overlapping-market ASCs, giving the nonprofit system more than 300 surgery centers across 35 states, behind only Tenet/USPI and Optum/SCA Health. The deal means all three of the sector’s largest ASC platforms now sit inside strategic parents rather than financial sponsors, a structural shift this vertical’s sources have flagged as building since early July. Separately, device maker Smith and Nephew announced an expanded “ASC Solutions” enterprise strategy on July 21, 2026, broadening its ASC ONE delivery model into a platform meant to help centers with development, procedural technology, and value-based contracting, evidence that device manufacturers are chasing the services layer around ASCs, not just supply contracts. Confidence: High on the Ascension close, Medium on how much revenue Smith and Nephew’s platform play actually captures. Sources: Ascension Closes AmSurg Deal Following FTC Scrutiny, Healthcare Dive, FTC Clears Ascension’s $3.9B AmSurg Purchase, Requires Some ASC Divestitures, Fierce Healthcare, Smith+Nephew Introduces Expanded Enterprise ASC Solutions Strategy, GlobeNewswire.
Clinical Policy
Surgical robots built for outpatient centers, not hospitals, just started doing real cases in ASCs, and a Medicare payment change from January is accelerating the shift. On March 5, 2026, the Surgery Center of Hackensack in New Jersey became the first US ASC to use the eCential Robotics platform, a robotic-assisted spine and neurosurgery system previously confined to hospitals. Separately, Distalmotion reported in May 2026 continued commercial momentum for its DEXTER system, a compact robotic platform designed specifically for the infrastructure and workflow constraints that have historically kept robotics out of outpatient settings. A Medicare reimbursement change effective January 1, 2026 is a big part of why: ASC-segment robotic-assisted surgery is now projected to grow at roughly 16 percent annually through 2031, well above the broader surgical robotics market, according to Mordor Intelligence. For operators, the question is no longer whether robotics belongs in an ASC, it is which procedures justify the capital outlay first; joints and spine are the leading candidates given existing device-intensive payment support. Confidence: Medium, adoption data so far is early and largely vendor-reported. Sources: Distalmotion Accelerates US Commercial Momentum in Ambulatory Surgery Centers, GlobeNewswire, NJ Neurosurgeon First to Use Robotic-Assisted Technology in an Ambulatory Surgery Center, PR Newswire, Soft Tissue Surgical Robotics 2026: New FDA Clearances, CMS Changes, and the ASC Opportunity, Spinnaker Life Sciences.
The Operator Metric
7.9 times EBITDA. That is the median price multiple ASC sellers got in 2025, the highest level in at least eight years, and the number every ASC owner should benchmark before taking a call from a buyer. The median total invested capital to EBITDA multiple for ASC transactions climbed to 7.9 times in 2025, according to VMG Health’s 2026 Healthcare M&A Report, the highest level VMG has tracked in at least eight years. Standard control-level deals still cluster around 7 to 8 times EBITDA, but select multi-specialty, high-growth centers with strong physician alignment are commanding double-digit multiples, and publicly traded Surgery Partners itself trades at roughly 12.7 to 14 times EV/EBITDA on 2026 projections. With all three top strategic platforms (Tenet/USPI, Optum/SCA, and now Ascension/AmSurg) actively buying, and private-equity sponsors hunting the middle market they have ceded at the top, owners weighing a sale or recapitalization should treat this multiple, not last year’s number, as the current benchmark. Confidence: Medium, VMG’s report aggregates private transaction data that is not independently auditable. Sources: Selling Your ASC in 2026: Key Valuation Drivers, VMG Health, How Much Are ASCs Actually Worth Right Now?, Healthcare Dealflow.