Navigating the Ambulatory Surgery Center Landscape for Electrophysiology: Challenges and Opportunities Ahead

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EP LAB DIGEST. 2026;26(5).

Cesar D Garcia, MS, RCIS, RT(R) (CI) (ARRT)
Chief Operating Officer, Apex Heart and Vascular Center, Glendale, Arizona

Ambulatory surgery centers (ASCs) continue to exert a profound influence on the delivery of cardiovascular care. Over the past decade, cardiovascular ACSs have redefined traditional approaches to elective cardiac treatment by demonstrating comparable safety, effectiveness, and efficiency metrics comparable to hospitals and cohort centers. These outcomes have strengthened confidence within the medical community that ASCs represent a safe and viable option for patients undergoing elective, nonacute care. 

In 2026, the Centers for Medicare & Medicaid Services (CMS) expanded reimbursement and coverage for a broader range of electrophysiology (EP) procedures, further encouraging greater adoption of the ASC setting by patients and providers. Although this shift presents significant opportunity, it also introduces challenges related to long-term sustainability. Key determinants of ASC reliability include patient selection, staffing, equipment costs, payer credentialing, and patient experience.

Patient Selection and Outcome Tracking
Appropriate patient selection for EP procedures affects multiple critical business drivers within the ASC, including efficiency, cost control, outcomes, and resource allocation. Therefore, when developing a patient selection framework, the following considerations are essential:

1. Clinical Stability
   • Patients should meet clinical criteria for nonacute status and be clinically stable, with no evidence of decompensation from a cardiac perspective.
    
2. Procedure Complexity
   •  Low-risk procedures (eg, diagnostic EP studies, simple ablations) should be prioritized. 
   •  Higher-complexity procedures often require additional resources (eg, anesthesia support, specialized equipment), which may negatively affect projected revenue. 
    
3. Comorbidities
   • Patients should have limited or well-controlled comorbid conditions (eg, chronic obstructive pulmonary disease, congestive heart failure, sleep apnea, renal disease). 
   • Patients must be able to tolerate light to moderate sedation and demonstrate an unobstructed airway on physical examination. 
    
4. Payer and Coverage Considerations
   • Coverage verification is essential to ensure that both primary and secondary insurers include the procedure in their fee schedules.
    
5. Recovery Considerations
   • Patients should be able to ambulate safely within a few hours postprocedure and have reliable transportation and postdischarge support. 

Outcome tracking programs are an essential component of an ACS’s structure and standards. Quality metrics should adhere to national regulatory standards, align with clinical best practices, and be supported by evidence-based guidance. These metrics collectively demonstrate the facility’s quality of care and directly influence CMS-supported reimbursements. Apex Heart and Vascular Center actively tracks (but is not limited to) these key initiatives:

• Hand hygiene compliance
• History & physical compliance
• Medication labeling compliance
• Procedure time-out compliance
• Sedation (ASA/Mallampati Score) assessment
• Antibiotic administration compliance 
• Access site complications, including major and minor bleeding
• Emergent/nonemergent hospital transfer 
• Surgical site infections

Accreditation organizations such as the Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission require ASCs to demonstrate compliance before licensing. State agencies may also add oversight and scrutinize these standards during inspections. These bodies expect ASCs to maintain systems for tracking discrepancies, implementing plans of correction (POCs), and monitoring progress. This ensures that the ACS has closed-loop processes to achieve clinical compliance and high-quality care.  

POCs are useful tools for actively addressing compliance metrics that are not within desired ranges. Successful programs institute regular and timely review of process discrepancies reflected by either trend data or singular events (ie, acute bleeding). These events are a key step in constructing and directing process changes that inform strategic decision-making and support the development of resilient, data-driven workflows. Therefore, it is advised that ASCs demonstrate a structured platform for reporting clinical quality that involves the clinical team, administration, and the physician board that all drive next steps and desired outcomes in a collective manner. 

Equipment Costs
Cost containment is a foundational principle of the ASC model, particularly when compared with hospital-based care. Achieving cost reductions begins with securing fair-market pricing agreements with vendors and suppliers that align with ASC operational needs. Implementing standardized preference-card systems by procedure improves cost predictability and supports accurate forecasting of revenue and procedural volume within defined reporting cycles. 

Additional strategies to manage equipment costs include the following: 

1. Development of physician- and procedure-specific preference cards 
2. Evaluation of cost-effective alternatives for commonly used items (eg, electrocardiogram electrodes, sutures, vascular closure devices, defibrillator pads, etc)
3. Annual review of pricing contracts and assessment of promotional purchasing opportunities
4. Establishment of target turnover times to optimize efficiency
5. Evaluation of disposable versus re-sterilized tools for implantable devices
6. Comparison of re-sterilized versus new EP catheters 

EP supply costs vary by arrhythmia type (eg, atrial flutter versus atrial fibrillation) and operator-specific requirements. Projecting case costs against anticipated procedural volume enables ASCs to proactively manage profitability while accounting for potential losses. Common sources of financial loss include excessive procedure duration and unanticipated equipment utilization. Evaluating EP services across the entire ASC portfolio provides insight into their overall financial impact and underscores the importance of strategic planning to maximize profitability while minimizing risk. 

Staffing
Staffing EP labs in the ASC setting remains a significant operational challenge. Ideally, ASCs aim to function with a high degree of independence, supported by staff who are proficient in procedure setup, EP study execution, troubleshooting, and postprocedural care. Unlike hospital environments, ASCs typically operate with leaner teams and limited access to ancillary services (eg, respiratory therapy, intensive care unit support, anesthesiology, etc). This underscores the need to recruit and retain highly skilled EP staff experienced in complex and critical care procedures and provide a diversity of skills that add value to the ASC. 

The availability of qualified EP clinicians, including registered nurses and radiologic technologists, is often limited. In the Southwest region, contributing factors include:

• Limited availability of formalized RCIS and RCES programs and inconsistent recognition of these credentials as specialized
• Competition from community hospitals with established EP programs, which dilutes the talent pool
• Migration of experienced staff into industry role
• Combined cath and EP laboratory models that require staff to take call for catheterization procedures during nights, weekends, and holidays
• Division of staff time among EP, coronary intervention, peripheral vascular, and structural heart procedures 
• Lack of compensation incentives for staff who demonstrate proficiency and/or achieve RCIS, RCES, or CEP certification

The key challenge for ASCs is maintaining compensation packages that are competitive with hospitals and peer ASCs, particularly for EP professionals. To attract and retain top talent, ASCs must leverage their strongest differentiator—work-life balance—while developing incentive structures that offset potential base salary reductions associated with transitioning from hospital settings.

Credentialing 
Establishing a strong network of private payers is essential to the financial viability of an ASC. The credentialing process is often lengthy and can be a source of frustration for newly established centers eager to generate revenue. Following state licensure and formal accreditation (eg, AAAHC, Joint Commission), ASCs must obtain a Provider Transaction Access Number (PTAN) from Medicare. The PTAN enables Medicare billing and is a prerequisite for contracting with commercial payers. 

Strategies to streamline this process include the following:

• Initiating Medicare and commercial payer applications early 
• Coordinating state licensure with AAAHC or Joint Commission accreditation to promptly address corrective actions and reduce delays
• Anticipating delays and communication gaps that may affect critical timelines
• Conducting early analyses of projected volumes, targeted CPT codes, payer market distribution, and provider credentials 

Payer contracting varies by insurer. Ideally, reimbursement rates should meet or exceed Medicare benchmarks. However, initial contract offers for newly established ASCs are often unfavorable due to the absence of historical performance data. Payers independently develop proposals, resulting in substantial variability in reimbursement. 

ASC financial models must account for this variability, particularly for high-volume procedures, and strategically balance lower-margin cases with more profitable services. There will be opportunities to renegotiate with each payer depending on the length of the initial contract. Demonstrating strong procedural volume, quality outcomes, and measurable cost savings during the first year—compared with hospital-based care—positions ASCs to negotiate from a position of strength.

Patient Experience
Patient experience is a cornerstone of ASC performance and a critical driver of long-term success. It reflects the integration of clinical excellence, operational efficiency, and compassionate care. A positive patient experience builds trust, fosters loyalty, and differentiates ASCs in an increasingly competitive marketplace. Patient experience is the defining metric for ASCs, setting them apart from hospitals and driving loyalty through personalized care and convenience.

ASCs should prioritize clear communication, streamlined scheduling, and personalized care plans to reduce patient anxiety and enhance comfort. Postprocedure follow-up, billing transparency, and staff accessibility for questions further reinforce patient confidence and demonstrate a commitment to delivering a care experience distinct from traditional hospital settings. 

Cultivating a patient-centered culture requires personal ownership from all ASC staff and a shared commitment to a customer-first mindset, understanding their role in the patient’s experience. Participation in formal patient experience benchmarking programs (eg, NRC Health, Press Ganey, etc) databases allows ASCs to compare performance with national peers, identify opportunities for improvement, and implement corrective actions quickly and efficiently. 

Key strategies to enhance patient experience include:

• Convenient ASC access (eg, preferred or covered parking, etc)
• Disclosure of patient financial responsibility at least 5 days before the procedure 
• Friendly, courteous front-desk interactions upon arrival
• A comfortable, well-designed waiting area 
• Efficient preprocedure evaluation and preparation 
• Clear communication regarding procedural expectations and pain management
• Thorough postprocedure communication and discussion of next steps by the physician
• Clear, concise discharge instructions
• Follow-up telephone contact within 5 days of the procedure 
• A standardized service-recovery process for addressing negative feedback 

Summary
As ASCs continue to reshape the cardiovascular care landscape, their role in EP will expand significantly. With CMS broadening coverage for EP procedures in 2026, ASCs face substantial opportunity alongside complex operational challenges. Long-term success will depend on strategic patient selection, disciplined cost management, sustainable staffing models, and effective payer credentialing. Equally important is fostering a patient-centered culture that emphasizes safety, transparency, and personalized care—key differentiators from hospital-based settings. 

By aligning operational efficiency with clinical excellence and maintaining a focus on sustainability, ASCs are well positioned to emerge as leaders in delivering high-quality, cost-effective EP services. The future of EP in the ASC setting is promising for organizations prepared to innovate, adapt, and consistently demonstrate value to patients and payers. 

Disclosures: Cesar Garcia, MS, RCIS, RT(R)(CI)(ARRT) has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest, and has no disclosures to report.