LUGPA Advocates for Adequate Reimbursement of New Technologies in the ASC Setting
LUGPA is urging CMS to ensure that Medicare payment policy encourages, rather than impedes, adoption of innovative technologies in ambulatory surgical centers (ASCs).
ASCs are an increasingly important site of Medicare outpatient care, providing appropriate services at generally lower payment rates than hospital outpatient departments. As CMS continues to expand the number of procedures that can be furnished in outpatient settings, adequate payment for new technologies will be essential to making that transition sustainable.
Newer procedures, however, may require specialized, high-cost, single-use devices that are integral to the service. If Medicare payment does not adequately recognize those costs, independent practices and ASCs may be unable to offer procedures sustainably, potentially limiting patient access or shifting care to higher-cost hospital settings.
LUGPA’s comments on the CY 2027 OPPS and ASC Proposed Rule will emphasize that early claims data may not accurately reflect the true cost of newly introduced technologies. LUGPA is asking CMS to consider reliable supplemental cost information, including documented acquisition and invoice data, when claims experience is limited or does not adequately capture the cost of an integral device.
CPT code 55882 provides an important example of this broader concern. As CMS establishes payment for newer technology-dependent procedures, LUGPA believes the agency should ensure that payment methodology accurately reflects the resources required to furnish those services.
LUGPA’s recommendations include:
- Applying CMS’s device-intensive criteria appropriately to new and emerging procedures.
- Ensuring device offsets and payment indicators accurately reflect the cost of integral, high-cost, single-use devices.
- Considering reliable supplemental cost information when early claims data are incomplete or insufficient.
- Exercising caution when establishing payment for newly introduced technologies.
- Ensuring payment policy supports appropriate migration of care to efficient ASC settings.
LUGPA will continue working with CMS to promote payment policies that support innovation, preserve beneficiary access, and strengthen independent practices.
LUGPA Comments on CY 2027 OPPS/ASC Proposed Rule
LUGPA submitted comments to CMS on the CY 2027 OPPS/ASC Proposed Rule, addressing several policies that could significantly affect independent urology practices and ambulatory surgery centers. LUGPA supported reforms that promote site-neutral payment, appropriate migration of care to ASCs, and more accurate payment for innovative technologies, while raising concerns about proposed changes that could reduce ASC reimbursement.
LUGPA urged CMS to finalize 340B payment reform, eliminate or modify the proposed ASC weight scalar, ensure adequate reimbursement for new urologic technologies and high-cost devices, and expand site-neutral payment policies. LUGPA also supported removing appropriate urologic procedures from the Inpatient Only List and expanding the ASC Covered Procedure List. Across its recommendations, LUGPA emphasized that Medicare payment policy should support efficient, physician-led care and patient access—not incentivize hospital ownership or higher-cost sites of care.
Medicare Physician Fee Schedule: LUGPA Urges Action on Physician Payment Stability
LUGPA continues to advocate for meaningful reform to the Medicare Physician Fee Schedule (MPFS) as CMS’s CY 2027 proposals would result in another reduction in Medicare physician payment.
Under the CY 2027 MPFS Proposed Rule, CMS proposed conversion factors of $33.17 for qualifying APM participants and $32.84 for non-qualifying APM participants. These represent decreases from the CY 2026 conversion factors of $33.57 and $33.40, respectively. The reductions are largely attributable to the expiration of the temporary 2.5 percent Medicare physician payment increase.
LUGPA is concerned that continued reductions in physician payment, combined with rising practice costs, place additional pressure on independent urology practices. The Medicare Economic Index (MEI), which measures changes in the costs of operating physician practices, continues to demonstrate that the cost of providing care does not remain static while Medicare payment updates remain constrained.
LUGPA is urging Congress to enact permanent Medicare physician payment reform tied to the MEI to provide greater stability and predictability for physician practices. A sustainable payment system is essential to preserving independent practice, maintaining access to specialty care, and ensuring that physicians can continue to invest in staff, technology, and other resources necessary to provide high-quality care.
LUGPA is also raising concerns with several specific CY 2027 MPFS proposals affecting urology.
Of particular concern is CMS’s proposal to reduce payment by 50 percent for the lower-valued service when certain same-day evaluation and management services are reported with Modifier 25. LUGPA believes this proposal fails to recognize that Modifier 25 already requires a significant, separately identifiable service and could reduce appropriate payment for services furnished during the same patient encounter.
LUGPA is also monitoring proposed changes to practice expense methodology and reductions affecting urology-specific supplies and procedures. These changes are particularly concerning because practice expenses continue to increase even as Medicare payment updates remain below the growth in the cost of operating a physician practice.
LUGPA believes these proposals should be evaluated in the context of their cumulative impact on independent practices rather than in isolation. Even relatively modest reductions can have a meaningful effect when layered on top of years of inadequate Medicare payment updates and rising labor, technology, facility, and supply costs.
The proposed MPFS changes reinforce the need for Congress to address the underlying instability in Medicare physician payment. Annual temporary fixes do not provide the predictability independent practices need to plan, invest, and remain viable.
LUGPA will continue advocating for a permanent, MEI-based approach to Medicare physician payment and opposing policies that would further undermine the ability of independent urologists to provide care in community-based settings.
Advocating for Coverage of HCPCS C9761
LUGPA is engaging health plans to advocate for appropriate coverage of HCPCS C9761, which describes cystourethroscopy with ureteroscopy and/or pyeloscopy, including lithotripsy and ureteral catheterization for steerable vacuum aspiration of the urinary tract. LUGPA recently developed and submitted a letter requesting reconsideration of payer policies that classify C9761 as experimental and investigational.
The letter highlights the growing body of clinical evidence supporting the procedure, including randomized controlled data, prospective multicenter studies, long-term follow-up, and real-world clinical evidence. The evidence demonstrates improved stone clearance and reduced residual stone burden while maintaining a comparable safety profile. Notably, two-year follow-up data demonstrated a 73% reduction in stone-related healthcare utilization, including emergency department visits, hospitalizations, and repeat procedures.
LUGPA is emphasizing that the evidence supporting C9761 has matured substantially and warrants reconsideration of restrictive coverage policies. The association will continue engaging payers to promote evidence-based coverage of C9761 and ensure patients have access to clinically supported advances in urologic care.
CY 2027 MPFS Financial Impact Calculator Helps Members Plan for 2027
LUGPA has partnered with Willow Run Analytics to launch an exclusive, interactive online portal to help members assess the financial impact of the newly released CY 2027 Medicare Physician Fee Schedule (MPFS) Proposed Rule. The new web-based tool replaces LUGPA’s Excel-based calculator, providing members with a faster and more dynamic way to model proposed Medicare reimbursement changes.
The portal allows practices to evaluate potential changes in Medicare revenue across specialties, providers, service lines, and individual CPT codes, providing valuable information for 2027 budgeting and financial planning. Pre-populated data includes 2024 Medicare utilization claims and GPCI-adjusted rates for 2026 and 2027, while practices can also update provider rosters and request customized analyses using current practice volume data.
To support members in using the new resource, LUGPA also made an on-demand instructional webinar available covering portal access, account setup, provider roster management, scenario analysis, and revenue impact reporting.
The portal is available at no cost to active LUGPA practice members through October 31, 2026, giving practices an important resource for understanding and preparing for the potential financial effects of the CY 2027 MPFS proposals.
Modernizing C-APC Payment to Protect Access to Innovative Urologic Care
LUGPA also developed recommendations for modernizing CMS’s Comprehensive Ambulatory Payment Classification (C-APC) methodology.
C-APCs generally provide a single bundled payment for a primary procedure and associated services, including certain drugs and biologics after applicable temporary pass-through payment status expires. While packaging can promote efficiency for routine services, it can create challenges when high-cost, innovative therapies are incorporated into payment rates based largely on historical claims and cost data.
The result can be a mismatch between the C-APC payment and the actual cost of acquiring and administering a newer therapy.
LUGPA believes the issue is not packaging itself, but ensuring that the methodology includes appropriate safeguards for therapies whose costs cannot reasonably be captured within an existing bundled rate. LUGPA is urging CMS to establish a targeted exclusion list or comparable payment mechanism for qualifying high-cost innovative therapies.
Accurate and predictable payment is particularly important in urologic oncology, where access to newer therapies can affect treatment options and continuity of care. Inadequate payment can also create incentives to shift services away from independent practices and toward hospitals, potentially increasing costs and reducing patient choice.
LUGPA will continue advocating for C-APC policies that preserve the efficiency of bundled payment while ensuring that innovative therapies remain financially viable in community-based specialty care.
No Surprises Act: LUGPA Monitors Significant QPA Decision
LUGPA is also closely monitoring significant developments in litigation over the No Surprises Act (NSA) and the methodology used by insurers to calculate the Qualifying Payment Amount (QPA).
On August 11, the U.S. Court of Appeals for the Fifth Circuit issued a significant decision addressing challenges to the federal methodology for calculating the QPA. The decision favored providers on important aspects of the methodology, including limitations on insurers’ ability to incorporate so-called “ghost rates”—contracted rates for services that a provider does not actually furnish—and restrictions on excluding certain risk-sharing, bonus, penalty, and other incentive-based compensation from QPA calculations.
The decision is important for independent physician practices because the QPA can have a substantial influence on negotiations and arbitration outcomes under the NSA. LUGPA has consistently advocated for a transparent and appropriately calculated QPA that does not allow insurers to artificially depress the benchmark used in payment disputes.
For independent practices, appropriate implementation of the NSA is particularly important. Practices often lack the negotiating leverage and administrative resources of large health systems or national insurers, making transparency, accurate payment benchmarks, and timely payment especially important to practice sustainability.
LUGPA will continue monitoring the implications of the decision and any subsequent guidance from federal agencies. The organization will also continue advocating for an IDR process that provides meaningful opportunities for providers to obtain fair payment while protecting patients from surprise billing.
CMS Proposes RAPID Pathway for Breakthrough Devices
LUGPA is also monitoring CMS’s proposed Regulatory Alignment for Predictable and Immediate Device (RAPID) coverage pathway, which is designed to accelerate Medicare coverage of certain FDA-designated Breakthrough Devices.
Under the proposal, CMS would engage with manufacturers earlier in the FDA approval process to identify clinical outcomes important to Medicare beneficiaries and align evidence requirements for FDA approval and Medicare coverage.
For eligible devices, CMS would begin the National Coverage Determination process when FDA market authorization is granted, with the goal of finalizing national Medicare coverage within 60 days for Class II devices and 90 days for Class III devices.
The pathway could provide important benefits for innovative urologic technologies by:
- Accelerating Medicare access to new devices;
- Providing greater certainty for practices considering adoption of new technologies;
- Reducing delays between FDA authorization and Medicare coverage; and
- Improving coordination between FDA approval and Medicare coverage.
Eligibility for the RAPID pathway would be limited, and certain technologies would not qualify. LUGPA will continue monitoring the proposal and assessing opportunities to support policies that provide timely and predictable Medicare coverage for technologies that improve patient care.
