ASC Facility Billing for Maryland's All-Payer Market

Maryland runs the country's only all-payer hospital rate-setting system. Under the HSCRC and the federal Total Cost of Care agreement, every payer — Medicare, Medicaid, and commercial alike — reimburses a Maryland hospital from the same regulated global budget, and the state is accountable for holding total per-capita spending down. That framework creates a genuine arbitrage: because a surgery center bills the ASC facility fee rather than a rate-regulated hospital charge, a case done at an ASC often costs a payer materially less than the same case inside a hospital's global budget. For a state whose entire waiver depends on bending the cost curve, the ASC is not a fringe setting — it is a policy-aligned way to lower total cost of care. The catch is that the arbitrage only holds if the center actually collects the facility fee cleanly and quickly; a run of denials or a stretched A/R cycle erases the very savings that make the ASC attractive.

Supply, meanwhile, is deliberately tight. The Maryland Health Care Commission enforces one of the firmer Certificate-of-Need regimes in the region, controlling whether and where a new or expanded ASC can open, so each licensed center carries real volume and each written-off claim stings. Maryland Medicaid pays an ASC facility rate, largely through its HealthChoice managed-care organizations; workers' comp cases price under the state schedule; and straight Medicare Part B claims flow through MAC Novitas Solutions under Jurisdiction JL.

When your entire value proposition is a lower total cost of care than the regulated hospital next door, every underpayment or write-off cuts straight into the savings that justify the case. Most of that loss is preventable and clusters around authorization, packaging, and out-of-network handling rather than clinical issues. Prior authorization is the largest single cause: an auth on the wrong CPT or site, or one that lapsed before surgery, stops a clean facility claim before it adjudicates. Each HealthChoice managed-care plan and commercial payer reads the covered list and auth rules its own way. Every leak below has a safeguard we build in before the claim leaves.

We bill the facility fee across the full range of Maryland centers and staff each account to its real case mix. GI and endoscopy centers built on screening-to-diagnostic conversions; ophthalmology and cataract ASCs managing IOL device offsets; orthopedic and spine centers carrying high-cost hardware and workers' comp exposure; pain-management ASCs; and ENT, urology, podiatry, plastic and reconstructive, multi-specialty, and physician-owned centers across Baltimore, Columbia, Rockville, Silver Spring, and the Washington, D.C. suburbs. We handle the facility claim only — the operating surgeon's professional fee and the anesthesia claim are filed separately by those providers, and we coordinate so nothing is double-billed. A screening-driven endoscopy center and an implant-heavy spine center run on opposite economics, so we build each account around its actual payer and procedure mix rather than a template, and we keep physician credentialing and payer enrollment current so a paneling gap never quietly holds a facility claim in a tightly-supplied CON market.