State Update

Prior Authorization

The Senate Committee on Insurance, Housing, Rural Issues and Forestry held a hearing October 29 on Senate Bill 434. The bill’s main authors are State Assembly Representative Barb Dittrich (R-Oconomowoc) and State Senator Rachael Cabral-Guevara (R-Appleton).

The legislation suggests a series of reforms:

• Requiring timely replies from insurance companies when a physician makes a prior authorization request: within 72 hours after receiving all necessary information as part of a regular request, and within 24 hours of an urgent request.
• Establishing minimum time period durations for an approved request: one year from issuance for non-chronic conditions and for the duration of treatment for chronic or long-term conditions.
• When a patient switches to a new health plan, the insurance company must honor a prior authorization approved by the patient’s former insurance plan for at least 90 days.
• Insurers cannot deny payment for an authorized service after it has been provided (i.e., no retroactive denials).

Others, including the Wisconsin Medical Society, have asked for an additional provision to ensure that insurance company adverse determinations (denials or reduction in coverage) can only be made by an insurance company representative who has the requested drug or service as part of their scope of practice.

Surgical Tech Certification

At this time, WISCA is register in opposition to the bill based on overwhelming feedback from members about the lack of need for the bill, the current standards in place to assure patient safety and the potential impact on an already limited workforce.

Surgical Smoke

WI AB563 was introduced October 24 – a companion to SB442 which was previously introduced. The bills require hospitals and ASCs to adopt and implement policies to prevent exposure to surgical smoke in operating rooms by requiring the use of a smoke evacuation system in the operating room during any surgical procedure that is likely to generate surgical smoke. Also includes an exemption, providing that the requirement does not apply to a health care provider who concludes that using a smoke evacuation system in an operating room during a surgical procedure is not necessary or advisable under the circumstances.

At this time, WISCA is neutral on the bill.  Feedback from members has suggested the bill would have little impact as most centers at risk of surgical smoke already have equipment in place.

Federal Update

CMS Rulemaking Update

ASCA reported that CMS has not yet released the 2026 OPPS/ASC Final Rule. We anticipate publication at any time, but continue to face uncertainty due to irregular release schedules and the ongoing government shutdown.

• ASCA noted that, under normal circumstances, the statutory deadline for the rule’s release would fall 60 days before the January 1 effective date; however, that timeline has now passed. The Medicare Physician Fee Schedule (MPFS) Final Rule, which typically precedes the ASC rule, was released after business hours on Friday, November 1, signaling that CMS is releasing materials later than usual.
• ASCA will continue to monitor CMS’s regulatory dashboard and other agency sources closely. The organization will issue an immediate alert to members once the final rule becomes available.

Medicare Physician Fee Schedule (MPFS) Final Rule Overview

ASCA has begun a detailed review of the MPFS Final Rule, which totals nearly 2,400 pages. The rule governs clinician reimbursement rather than facility rates, but changes within it have downstream impacts on ASC volume and physician practice behavior.

• ASCA has identified two finalized policies with significant implications for ASC-based physicians and surgical specialists:
• • Reallocation of the Indirect Practice Expense: CMS finalized a reallocation that shifts the share of practice expense reimbursement from facility-based procedures toward non-facility services. This change will reduce overall reimbursement for physicians performing procedures in ASCs or hospitals. Based on CMS’s published impact tables, expected decreases include: ophthalmology (-12%), cardiology (-6%), and gastroenterology (-9%).
  • Implementation of an “Efficiency Adjustment” to Work RVUs: CMS introduced a policy assuming certain services become more efficient over time, resulting in an automatic downward adjustment to payment rates. Unlike the ASC payment system, which includes an inflationary offset, the MPFS lacks such a balancing factor. Consequently, this policy creates an annual, compounding reimbursement reduction without corresponding inflation updates.
• ASCA opposed both provisions in its formal comments, joining nearly all major physician organizations that submitted similar concerns. Despite widespread opposition—approximately 14,000 to 15,000 total comments—CMS finalized both policies largely unchanged.
• ASCA noted that, while clinicians will receive a temporary 2.5% increase to the conversion factor as part of the Big Beautiful Bill Act, the broader structural issues remain unresolved. The organization expects continued advocacy by specialty societies and will coordinate with them to support corrective legislative efforts.

Ambulatory Specialty Model Proposal

CMS finalized a framework for a new Ambulatory Specialty Model (ASM), intended to apply to cardiology, anesthesiology, pain management, and spine-related specialties. The program builds upon elements of the Merit-Based Incentive Payment System (MIPS) but introduces new quality reporting measures specific to these fields.

• The ASM is scheduled to begin on January 1, 2027, and will initially apply to approximately 25% of clinician specialties. CMS dedicated roughly 400 pages of the rule to outlining the model’s structure and data collection approach.
• ASCA will engage with specialty societies affected by this proposal to assess the administrative burden, reporting feasibility, and potential interaction with existing ASC quality measures. The organization plans to prepare a written analysis for publication in ASC Focus, Digital Debut, and the Government Affairs Update.

New Model Legislation: NASHP Site Neutrality Model

The National Academy for State Health Policy (NASHP), the same organization that helped fuel the facility fee prohibition trend with model legislation they published in 2021, has now released model state legislation on site neutral reimbursements, announced in a 10/27 blog post. Despite the blog post stating that, "the policy seeks to address the rising prices for care provided within hospital-owned or affiliated outpatient providers that can be safely and appropriately delivered at a lower price in an independent physician's office," the model legislation itself is written more broadly and would impact ASCs. See below for a brief summary:

• All health care providers that enter into a health care contract to be a participating provider with a health benefit plan must offer to accept as payment in full for all applicable services, rates that shall not exceed 150% of the amount paid as the Medicare non-hospital rate for those same services (NOTE: the percentage multiple of Medicare can be subject to change based on a state's objectives and projected savings estimates).
• No health care provider shall charge, bill or accept payment for an applicable services that exceeds the lesser of: 150% of the amount paid by Medicare non-hospital rate; or the negotiated rate agreed upon by the health care provider and the health benefit plan.
• No health care provider shall charge, bill, collect or otherwise demand payment for any applicable service on an institutional claim form such as a UB-04 or CMS-1450. A professional claim, such as CMS-1500 form shall be used exclusively to bill for any applicable service. In no circumstance should both a professional claim and an institutional claim be charged or billed for the same service.
• Definitions:
• • "Applicable services" defined as outpatient or ambulatory items or services that can be provided safely and appropriately across ambulatory care settings, including:
  • • the services, as identified by Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, contained within the sixty-six ambulatory payment classifications (APCs) identified by the Medicare Payment Advisory Commission (MedPAC) in its June 2023 Report to Congress recommending a site-neutral payment policy, and any subsequent APCs or services so designated by MedPAC;
    • any outpatient or ambulatory item or service recommended or required to be paid on a site-neutral basis by federal or [state] statute, the U.S. Department of Health & Human Services, or the Medicare Payment Advisory Commission (MedPAC), including without limitation,  evaluation and management office visits, wellness visits, physical therapy, occupational therapy, speech language pathology, and mammography (screening and diagnostic); and
    • any other outpatient or ambulatory items or services as designated by the [Department/Commissioner/Secretary] as safe and appropriate to be provided in lower-cost settings.
  • "Health care provider" defined as an individual, entity, corporation, person, or organization, whether for profit or nonprofit, operating under [state licensing statute] that furnishes, bills or is paid for health care service delivery in the normal course of business, and includes hospitals, hospital extension clinics, diagnostic and treatment centers, physician offices, or urgent care clinics, as well any affiliated provider or entity billing for health care goods or services delivered at the health care provider’s facility as an employee, contractor, a clinical faculty member, or otherwise.
  • "Medicare non-hospital rate" defined as the amount paid by Medicare for those same services pursuant to the Medicare Physician Fee Schedule, set forth under 42 U.S.C. § 1395w-4, or the Ambulatory Surgical Center (ASC) Payment System, set forth under 42 U.S.C. § 1395l(i)(2)(D), according to the site of service recommended by MedPAC as the reference rate where applicable.

The Association of Wisconsin Surgery Centers invites interested members to volunteer to serve on the board or a committee. Board nominations due by September 10. A ballot will be sent out to members following the close of nominations with election results announced in October.

More information on eligibility and responsibilities for the board and committees is available on our website.

Thank you for all you to provide high-quality, low-cost care to so many in our state.  Together, our centers have helped transform the outpatient experience through a more personalized surgical center.

Nationally, ASCs have saved the Medicare program an estimated $7 billion.  And at a state level, Wisconsin’s 76 Medicare-certified centers have saved Medicare over $52m since 2022!

Information and resources on National ASC Month available on the ASCA website.

There are a number of state issues of interest to surgery centers.

The bill to license Surgical Technicians continues to be discussed by legislators.  Changes to the bill are under considering in response to concerns raised by health care organizations about the cost and workforce impact.  Thank you to our members who completed the online survey – and stay tuned for more information WISCA.

Legislators and a coalition of organizations led by the Wisconsin Medical Society are reviewing prior authorization legislation.  Your feedback on the impact of prior authorization is key to the coalition’s continued work on this issue.  There is still time to share your stories.

Governor Evers announced his decision not to run for a 3^rd term as Governor, leaving the race for Governor wide open for the first time since 2010.  Several candidates have announced plans to run, with more expected in the near future.  Certainly promises to be a busy campaign – in the midst of the highly anticipated national mid-term congressional elections.

We previously shared that UHC plans to change reimbursement of anesthesia services effective October 1.  More specially, the change would reduce reimbursement for CRNAs by 15% - placing a significant strain on facilities employing a CRNA model.  If you have not yet, please complete the survey to collect more information which will support WISCA’s participation with partner organizations in addressing this issue.

The Agency for Healthcare Research and Quality (AHRQ) recently published a survey on Patient Safety Culture in response to interest from ambulatory surgery centers.  The survey is designed specifically for ASCs staff and asks opinions about the culture of patient safety in the ASC.  Survey results will help assess patient safety culture in facilities.  Surveys are due June 20.  Visit the AHRQ website for more information on the survey form, survey items and composite measures.

Patient Safety Culture Survey

A number of statewide organizations are working on legislation to provide prior authorization protections in state law. WISCA is working with these organizations and helping prepare for the introduction of this legislation and eventual hearings. We are asking members to share their experience to advance this important policy change. Please share examples of how current prior authorization practices impact your center.  Most notably, share how prior authorization impacts the quality and cost of care to your center and your patients. Your feedback is very important – please take a few minutes to complete a short online survey.

Complete the Survey

A bill relating to certification of surgical technicians has been introduced (SB 260/AB 261).  Provisions of this bill would require surgical technicians to hold and maintain certification from a national and accredited certifying body that certifies surgical technologists as well as requiring completion of an accredited educational program for surgical technologists.  More detail below from the Legislative Reference Bureau’s analysis.

We have received mixed feedback on the bill.  Some suggest the new statutory change is unnecessary and would make it more expensive/cumbersome to become a surg tech, thus diminishing the pool in an area where it is already difficult to find employees.  While others believe the bill would have little impact as they are already abiding by these protocols.

Prior to officially moving forward in opposition we wanted to gain any final additional feedback from WISCA members.  Thank you for your consideration and please let us know your thoughts.  Please pass along your feedback on the bill online by June 17.

Submit Your Feedback

 Analysis by the Legislative Reference Bureau:

This bill prohibits hospitals and ambulatory surgical centers from employing or otherwise retaining any individual to perform surgical technology services unless the individual is qualified as provided in the bill. “Surgical technology” is defined under the bill to mean surgical patient care and includes: 1) collaboration with a team of health care providers prior to a surgical procedure to carry out the plan of care by performing certain preparatory tasks; 2) intraoperative anticipation and response to the needs of a surgeon and other team members in the operating room by monitoring the sterile field and providing the required instruments or supplies in the sterile field; and 3) performance of tasks in the sterile field as directed in an operating room setting, including passing supplies, equipment, or instruments; sponging or suctioning an operative site; preparing and cutting suture material; handling specimens; and holding retractors.

To qualify to perform surgical technology services under the bill, an individual must satisfy one of several possible criteria, including 1) successfully completing a training program for surgical technology in connection with the individual’s military service, or 2) successfully completing an accredited educational program for surgical technologists and holding and maintaining a certification as a surgical technologist from a national and accredited certifying body. The bill provides that a hospital or ambulatory surgical center may employ or otherwise retain the services of an individual to perform surgical technology services during the 24-month period that immediately follows the individual’s successful completion of an educational program for surgical technologists. The bill provides that these requirements do not apply to a licensed health care provider who may provide surgical technology services within their scope of practice. Further, the bill provides that a hospital or ambulatory surgical center may establish additional requirements for any individual who performs surgical technology services as a condition of employment or contract.

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Participation is open to the entire ASC community. WISCA members can save $150 on survey subscriptions by using the following promo code:

WIBENCH25

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Clinical & Operational Benchmarking Survey

Make sure your facility’s compensation packages are competitive so you can attract and retain the best employees.

ASCA’s Salary & Benefits Survey is a vital tool that collects national, regional and state data on 20+ ASC positions, and allows you to benchmark your facility’s compensation packages with those offered at similar ASCs.

The 2025 Salary & Benefits Survey will be open June 1–30, and results will be available in July. This survey will not be conducted again until 2027, so make sure your ASC participates this year!

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WISCA members that don’t participate in the survey, or that complete less than 40 percent of the survey, can purchase results at ASCA’s discounted member price of $299 (savings of $100) by using the following promo code:

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Note: This code will not work until survey results are available in July.

Salary & Benefits Survey   

WISCA members shared an interest in monitoring prior authorization policy changes in the state. The following is a summary of recent developments:

1) The State’s Joint Committee on Finance recently met to review budget items included in Governor Ever’s state budget.  On May 8 they voted on party lines to remove what were considered “policy” items from the budget.  These include 2 proposals from the Office of the Commissioner of Insurance.

2) Assembly Health Committee Chair Clint Moses (R-Menomonie) announced at plans to introduce legislation that would reform prior authorization process in the state.  His goals are to have greater consistency among insurers, speed up the process in order to prevent any care delays and reduce provider burdens.