Case volumes are up. The rooms are full. The schedule is packed.

And yet, margins are shrinking.

That is the story heading into the 2026 ASCA Conference. Growth is real. But four cost pressures are hitting at the same time:

If you run a 5 to 20 physician group and are not thinking about a sale, your billing setup probably feels like an ops problem — not a strategic one. That view costs practices real money when a deal process starts. As MSMS advisory guidance from April 2026 notes, billing gaps and charge capture issues have shaped more than 40% of provider-side M&A deals. This leads to lower valuations, re-negotiations, or deals that fall apart.

Your original Medicare billing rules changed on January 1, 2026. If your practice is in Arizona, New Jersey, Ohio, Oklahoma, Texas, or Washington, this affects you now. The CMS WISeR pilot requires prior authorization for 17 outpatient procedure categories. Claims without PA are being denied.

United Healthcare made a big move on April 20, 2026. It announced it will remove most prior auth (PA) requirements for about 1,500 rural hospitals. That includes all Critical Access Hospitals. It also cut payment timelines from 30 days to under 15 days on average. For rural revenue cycle teams, this is real relief.

CMS continues to refine how payments differ by care setting in 2026, making site-of-service accuracy more financially impactful than before.

A new medical device gets FDA approval. Your doctors want to use it. The clinical case is strong. But Medicare will not cover it yet. So, you wait. Sometimes 12 months, sometimes 18 months, and sometimes longer.

The numbers have been public since December 2025. CMS finalized its CY2026 payment rates, and the arithmetic for ambulatory surgery centers has not changed in the way it needed to. The ASC conversion factor sits at $56.322. The Hospital Outpatient Department (HOPD) conversion factor is $91.415.

A safety-net hospital in a major metro area closed this year. It served around 100,000 patients. Many of them had no other nearby option. The operator blamed a billing system failure for a year of lost revenue. A state regulatory audit found more problems on top of that. The hospital is now shut. The patients are displaced.

Payments slow to a crawl. Claims pile up. Staff hours vanish on prior auth calls. Cash flow gets shaky.

Chaos rules revenue cycle management. Leaders feel it every day. You’re not imagining the pressure. It’s real. And it’s getting worse.

A federal judge dismissed a complaint filed by a major national insurer on April 9. The ruling was clear: courts cannot second-guess arbitration outcomes under the No Surprises Act’s Independent Dispute Resolution process. The insurer had challenged over 1,500 IDR proceedings. It claimed nearly half were ineligible. The court did not agree. The No Surprises Act made IDR a binding process. Federal courts cannot relitigate the results.