HHS OIG Data Brief  September 2019  OEI-01-15-00400 
 
Medicares Oversight of Ambulatory Surgery 
Why OIG Did This Review 
Centers:  A Data Brief 
Because ASCs often perform 
To participate in Medicare, ambulatory surgery centers (ASCs) must 
complex medical procedures, 
demonstrate that they meet Medicares minimum requirements.  Most (known 
including invasive surgeries under 
as nondeemed ASCs) undergo a State agency survey to do so; the others 
general anesthesia, we examined 
(known as deemed ASCs) are accredited by a Medicare-approved accreditor. 
how Medicare ensures that ASCs 
meet minimum health and safety 
What OIG Found 
requirements through its State 
State Survey Coverage:  States largely met Medicares requirements to survey 
survey process.  States also 
25 percent of nondeemed ASCs in fiscal year (FY) 2017, and nearly half met 
conduct investigations of 
Medicares requirement to have surveyed all ASCs within the prior 6 years.  
  complaints that allege poor care or 
Exhibit 1:  In FY 2017, States largely met Medicares requirements to  other problems at ASCs.  Medicare 
survey ASCs but some States fell short.  beneficiaries are increasingly using 
Met or were very close  ASCs for outpatient surgical 
to meeting both  procedures.  In fact, Medicare 
requirements  payments to ASCs increased from 
Clearly did not meet the  $3.4 billion in 2011 to $4.6 billion in 
 
25-percent requirement  2017.   
C learly did not meet the  OIG previously assessed the 
6-year requirement  frequency of ASC State 
certification surveys in 2002, when 
Clearly did not meet 
 
we found that nearly a third of 
either requirement 
nondeemed ASCs had gone 5 or 
Trends in Deficiencies:  States cited 77 percent of nondeemed ASCs with at  more years without a survey.  
least one deficiency in their most recent survey, and one-quarter of ASCs had  Since that time, outbreaks of 
serious deficiencies.  From FY 2013 to FY 2017, infection control deficiencies  healthcare-associated infections 
were the most frequently cited category of deficiency, making up about a fifth  have raised concerns about patient 
of all deficiencies.  health and safety at ASCs. 
Trends in Complaints:  From FY 2013 through FY 2017, States received 
How OIG Did This Review 
complaints for fewer than 4 percent of ASCs each year, but the share of those 
We analyzed data provided by 
complaints that required an onsite survey more than tripled.  
Medicare: (1) State data on ASC 
  certification surveys for 
What OIG Concludes 
nondeemed ASCs; and 
The Centers for Medicare & Medicaid Services (CMS) has made progress in 
(2) complaints about deemed and 
strengthening oversight of ASCs and addressing vulnerabilities that the Office 
nondeemed ASCs from FY 2013 to 
of Inspector General (OIG) has previously identified, and more can be done.  
FY 2017.  Using these data, we 
The results of this new analysis can support CMS in further strengthening its 
assessed State survey performance 
oversightparticularly of the few States that are falling short of meeting its 
against Medicares requirements 
requirements.  It can also help CMS focus on ASCs recurring challenges in 
and analyzed trends in deficiency 
meeting health and safety requirements, especially for infection control.
citations from State surveys and 
trends in complaint surveys.   BACKGROUND 
The shift of surgical procedures to outpatient settings has given rise to 
an increase in the number of ambulatory surgery centers (ASCs) over the 
past few decades.  From 2006 to 2017, the number of ASCs grew by 
25 percent, from 4,490 to 5,603 ASCs.1, 2  Medicare payments to ASCs 
totaled $4.6 billion in 2017.3   
The Centers for Medicare & Medicaid Services (CMS) primary oversight tool 
for ensuring the health and safety of patients at ASCs is the survey and 
certification process.  The Office of Inspector General (OIG) examined 
Medicares quality oversight of ASCs in a series of reports in 2002 and found 
that nearly a third of ASCs certified by State agencies went 5 or more years 
without a survey.4,5,6  At that time, CMS did not set a minimum requirement 
for how often State agencies needed to survey ASCs.  Since those reports, 
outbreaks of healthcare-associated infections have raised concerns about 
infection control at these facilities.7,8   
OIG has not assessed the frequency of ASC State certification surveys since 
2002.  This data brief provides an updated analysis of how States are 
meeting CMS requirements for State ASC surveys, including insights into the 
findings of those surveys.  This information contributes to OIGs body of 
work on Medicares quality oversight. 
Ambulatory Surgery Centers that Participate in Medicare 
An ASC is a distinct entity that exclusively provides surgical services to 
patients who do not require hospitalization.  ASCs perform only services 
that ordinarily would not take more than 24 hours (including pre-operative 
and recovery time) and that CMS judges can be safely performed on 
an ambulatory basis.9, 10  Services provided in ASCs range in complexity from 
simple surgeries, such as biopsies, to surgeries performed under general 
anesthesia, such as inserting a permanent pacemaker.  Cataract surgeries, 
upper gastrointestinal endoscopies, and colonoscopies with biopsy are 
among the most commonly performed procedures in ASCs.11  
CMS has established baseline health and safety requirements, called 
Medicare Conditions for Coverage (CfCs), that ASCs must meet to be 
eligible for participation in Medicare.  The 14 CfCs cover topics ranging from 
credentialing and privileging of surgeons to infection control and ASCs 
quality improvement programs.12  Each CfC covers a broad area 
(e.g., surgical services or infection control) and then is further defined by 
a set of specific standards that ASCs must meet. See Appendix A for a full 
list of the 14 CfCs.    
 
 
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   1 
OEI-01-15-00400   
Certification Surveys 
To participate in Medicare, ASCs must demonstrate that they meet the CfCs.  
Most ASCs do this by undergoing an onsite inspection, called a certification 
survey, conducted by their respective State survey and certification agencies 
on behalf of CMS.13  (In this 
report, we refer to these State 
Nondeemed and Deemed ASCs 
agencies as States.)  
Alternatively, ASCs can elect to  Nondeemed ASCs are certified by 
their respective State agencies. The 
be accredited by 
majority of ASCs are nondeemed. 
a CMS-approved accreditation 
organization instead of  Deemed ASCs demonstrate that they 
undergoing inspection by  meet the CfCs by becoming 
their respective States.14   accredited by a CMS-approved 
accreditor. 
These ASCs are referred to as 
deemed facilities, and make 
up a little under a third of all ASCs. 
To direct States in prioritizing their certification responsibilities, CMS sets 
performance standards for States in overseeing ASCs.15  CMS organizes 
these requirements by level of priority, with Tier 1 as the highest priority (see 
Exhibit 2).  
 
Exhibit 2:  CMS Table of Survey Frequencies and Priorities, Fiscal Year 
(FY) 2017
 
Source:  CMS, FY 2017 Mission & Priority Document. 
 
Tier 1 addresses accreditors surveys of deemed ASCs by requiring State 
validation surveys of a sample of deemed ASCs.  This report focuses on 
CMSs Tier 2 and Tier 3 requirements, which both concern nondeemed ASCs 
and constitute CMSs top two priority requirements for nondeemed ASCs.  
The majority of ASCsabout two-thirdsare nondeemed, underscoring 
the importance of the States oversight roles. 
 
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   2 
OEI-01-15-00400  When a State conducts a certification survey, it may find that an ASC does 
not meet one or more requirements.  If the State finds the ASC is out of 
compliance, it must determine whether the lack of compliance is at the 
standard level (less serious) or the condition level (more serious) by 
considering how serious the deficiency is in terms of its potential or actual 
harm to patients and the extent of noncompliance.  If the State finds that 
substantial noncompliance with multiple standards of a CfC adds up to 
pervasive noncompliance, or if it determines that noncompliance with one 
or more standards poses a serious threat to patient health and safety, it will 
cite the ASC with a condition-level deficiency.16 
After conducting a certification survey of an ASC, the State communicates 
its determination of compliance or noncompliance with CfCs to the 
surveyed ASC.  In instances of noncompliance, the ASC must submit a plan 
to achieve compliance for each cited deficiency.  
Complaint Investigations 
Patients and others can file complaints with CMS regional offices or States 
alleging poor care or other problems at ASCs.17   CMS requires States to 
conduct onsite investigations for the most serious complaints.  The required 
timeframes for investigations depend on the seriousness of the allegation.  
See Exhibit 3 for complaint priority levels and required timeframes.18  States 
may conduct complaint surveys of any ASC in Medicare, including deemed 
ASCs. 19   
Exhibit 3:  Priority Levels of Complaints Regarding ASCs 
Source: CMS State Operations Manual, ch. 5, Complaint Procedures (Revised 155, 06-10-16). 
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   3 
OEI-01-15-00400   
Previous Work 
In 2002, OIG issued three reports on the quality oversight of ASCs in 
Medicare.20, 21, 22  These reports assessed States and accreditation 
organizations oversight of ASCs and how CMS held them accountable to 
Medicare and the public.  OIG found problems with the oversight of ASCs, 
including ASCs that went for extended periods between State certification 
surveys and CMSs doing little to hold States and accreditors accountable.  
CMS implemented OIGs recommendations to establish a minimum survey 
cycle for ASCs; update the CfCs; and improve accountability of States and 
accreditation organizations. 
In 2009, the Government Accountability Office (GAO) recommended that 
CMS improve its data collection on infection control practices at ASCs 
following a series of high-profile cases of healthcare-associated infections at 
ASCs.23  CMS agreed with GAOs recommendation. 
 
   
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   4 
OEI-01-15-00400  FINDINGS 
States largely met  Most States met, or were close to meeting, CMSs highest priority 
requirement for certifying nondeemed ASCssurveying 25 percent each 
CMSs requirement 
year.  In FY 2017, 35 out of 50 States appeared to have met the requirement, 
to survey 
and an additional 7 States appeared to have been within about 1 survey 
25 percent of  short of meeting it.24  The remaining eight States missed the requirement 
nondeemed ASCs  by two or more surveys.  See Appendix B and Exhibit 4 for State-level 
compliance with this requirement.  
in FY 2017, and 
 nearly half met its 
requirement to  Exhibit 4:  In FY 2017, most States surveyed at least 25 percent of 
survey all ASCs  nondeemed ASCs. 
within the prior 
Surveyed at least 
6 years 
25% of ASCs 
Was about one 
 
survey short of 
surveying 25% of 
D ASCs 
Surveyed fewer 
than 25% of ASCs 
(short by two or 
more surveys) 
Had no 
nondeemed ASCs 
at the time of our 
analysis 
 
      Source: OIG analysis of CASPER and ASSURE datasets, 2019. 
 
In FY 2017, not quite half of States (22 of 50 States) met CMSs requirement 
to ensure that no more than 6 years elapse between surveys for 
an individual ASC.  However, most of the States that missed that 
requirement fell short by a small margin.  Specifically, 24 States had 
surveyed between 90 and 99 percent of ASCs within the past 6 years.  For 
the remaining four States, the percentage of ASCs surveyed within 6 years 
ranged from 48 to 85 percent.  Nationally, the data show that in FY 2017, 
States had surveyed 96 percent of nondeemed ASCs within the past 6 years.  
See Appendix B and Exhibit 5 for State-level compliance with this 
requirement.  
 
 
 
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   5 
OEI-01-15-00400  Exhibit 5:  In FY 2017, 22 States had surveyed all of their nondeemed ASCs 
within the past 6 years. 
Surveyed 100% of 
ASCs 
Surveyed 9099% 
of ASCs 
D
Surveyed fewer 
than 90% of ASCs 
surveyed 
Had no 
nondeemed ASCs 
at the time of our 
analysis 
 
    Source: OIG analysis of CASPER and ASSURE datasets, 2019. 
 
A few States fell short across both requirements.  Eleven States failed to 
meet both the requirement to survey 25 percent of nondeemed ASCs each 
year and the requirement to let no more than 6 years elapse between 
surveys for any nondeemed ASC.  Notably, three of those StatesHawaii, 
Nevada, and New Jerseymissed both requirements by clear margins.  See 
Appendix B for percentages of ASCs that States surveyed.  
 
States cited about  When States conduct their certification surveys, they often identify 
three-quarters of  deficiencies that can affect patient care.  During their most recent surveys 
for the nondeemed ASCs in our review, States cited 77 percent with one or 
nondeemed ASCs 
more condition-level or standard-level deficiencies.   
with at least one 
As part of these surveys, States cited 25 percent of nondeemed ASCs with 
deficiency in their 
one or more of the more serious (condition-level) deficiencies.  
most recent 
A condition-level deficiency indicates that substantial noncompliance with 
survey;  multiple standards of a CfC adds up to pervasive noncompliance, or that 
noncompliance with one or more standards poses a serious threat to 
one-quarter of 
patient health and safety.  See Appendix A for a full list of ASC survey CfCs.    
ASCs had serious 
   
deficiencies 
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   6 
OEI-01-15-00400  More commonly, States cited nondeemed ASCs with standard-level 
deficiencies.  Most ASCs (76 percent) had one or more standard-level 
deficiencies, which indicate that an ASC was noncompliant with one or more 
standards within a CfC, but not to the degree of a condition-level deficiency.  
See Exhibit 6 for a breakdown of nondeemed ASCs cited with deficiencies in 
their respective most recent surveys.  
 
Exhibit 6:  States cited three-quarters (77 percent) of nondeemed ASCs 
with a deficiency in ASCs' most recent certification surveys.
77% of all ASCs: Any level of deficiency
76% of all ASCs: Standard-level deficiency
25% of all ASCs: Condition-level deficiency
NOTE:  A State can cite both a standard-level and condition-level deficiency in a single 
survey.
Source:  OIG analysis of CASPER dataset, 2019.
 
 
   
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   7 
OEI-01-15-00400  The average  From FY 2013 through FY 2017, the mean number of total deficiencies per 
certification survey decreased from 6.1 to 4.2 for nondeemed ASCs. 25  Both 
number of 
condition-level and standard-level deficiencies per survey decreased (see 
deficiencies per 
Exhibit 7).  These decreases could reflect improvements in ASC performance 
survey decreased  and/or changes in how States assessed compliance.  
from FY 2013 
 
through FY 2017;  Exhibit 7:  From FY 2013 through FY 2017, the mean number of 
 
infection control  deficiencies per survey decreased from 6.1 to 4.2. 
deficiencies  Mean condition-level 
7
deficiencies per survey 
remained the most  y 
e
v
r 6  
prevalent  u
er s 6.1   FY0 2.80 13 
p
s  5  
e
ci FY 2017 
n
cie 4 0.5 
defi 4.2    
of  3 Mean standard-level 
r 
be deficiencies per survey 
m
nu 2  
n    FY 2013 
a
Me 1 5.3 
 
FY 2017 
0
3.7 
2013 2014 2015 2016 2017  
 
Source:  OIG analysis of CASPER dataset, 2019. 
 
ASCs appear to struggle with maintaining compliance with infection control 
requirements.  States cited slightly more than half (55 percent) of all 
nondeemed ASCs with one or more infection control deficiencies in the 
ASCs most recent certification surveys.  States cited ASCs with infection 
control deficiencies much more frequently than other kinds of deficiencies 
(see Exhibit 8).  One example of an infection control deficiency would be 
failure to ensure that surgical equipment is sanitized properly. 
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   8 
OEI-01-15-00400  Exhibit 8:  States cited over half of nondeemed ASCs with infection 
control deficiencies in ASCs' most recent certification surveys. 
Top five CfC deficiencies:                                                     
Percentage of ASCs with the following 
types of deficiency citations 
55
Infection control  55% 
Condition-level:  12% 
Standard-level: 54%  37%
Pharmaceutical services  37% 
Condition-level: 4% 
Standard-level: 37% 
Environment  33% 
Condition-level: 9% 
Standard-level: 32% 
Patient rights  30% 
Condition-level: 2% 
Standard-level: 30%  30%
Patient admission, assessment, and   28% 
discharge 
Condition-level: 2% 
Standard-level: 28% 
NOTE:  A State can cite multiple CfC deficiencies and both condition-level and standard-
level deficiencies in a single survey. 
 
   Source: OIG analysis of CASPER dataset, 2019. 
 
Infection control remained the most commonly cited category of deficiency 
(both at the standard level and at the condition level) in certification surveys 
of nondeemed ASCs from FY 2013 through FY 2017.  Between 19 and  
22 percent of all deficiencies cited each year concerned infection control.  In 
comparison, for 4 of these 5 years, the next most frequently cited category 
was patient  rights, which accounted for 12 to  16 percent of deficiencies each  
year.    
 
   
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   9 
OEI-01-15-00400  From FY 2013  Complaints serve as warning signs of possible shortfalls in patient care and 
safety.  From FY 2013 through FY 2017, States received 752 complaints 
through FY 2017, 
about ASCs, ranging from 130 complaints in FY 2013 to 186 complaints in 
States received 
FY 2014.  See Exhibit C-1 in Appendix C for total number of complaints per 
complaints for 
State over this time.  However, the proportion of the most serious 
fewer than  complaintsthose that the State categorized as immediate jeopardy and 
non-immediate jeopardyhigh, thus requiring an onsite surveyincreased 
4 percent of ASCs 
over this time (see Exhibit 9).  
each year, but the 
share of those  Exhibit 9:  The proportion of Immediate Jeopardy and Non-
Immediate Jeopardy - High complaints within total complaints 
complaints 
increased from 15 percent to 54 percent from FY 2013 through          
requiring an onsite 
FY 2017.
survey more than 
200
tripled  
180
 
s 160
t
n
ai
pl 140
m
o
c 120
f 
o
r 
e 100
b
m
u
N 80
60
40 52% 54%
20 24% 34%
15%
0
2013 2014 2015 2016 2017
 
Source: OIG analysis of ACTS dataset, 2019. 
 
Between FY 2013 and FY 2017, the most common complaints about ASCs 
related to quality of care and treatment and to infection control (see 
Exhibit 10).   
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   10 
OEI-01-15-00400  Exhibit 10:  The most common complaint allegations from FY 
2013 through FY 2017 relate to quality of care and treatment.  
35% Quality of care and treatment
n
o
ti
a
eg 24% Infection control
all
h 
t
wi
s  19% Patient rights
t
n
ai
pl
m
o 14% Nursing services
c
of 
e 
g
a 13% Physical environment
t
n
e
c
r
e
P
11% Physician services
 
Source: OIG analysis of ACTS dataset, 2019. 
 
States substantiated allegations for almost half of the complaints that they 
investigated.  Specifically, States investigated 632 of the 752 total 
complaints they received between FY 2013 and FY 2017 and substantiated 
1 or more allegations for 47 percent of them.26  The proportion of 
complaints with substantiated allegations ranged from a high of 51 percent 
in 2015 to a low of 42 percent in 2017.  When States substantiate 
a complaint, they may or may not cite deficiencies related to the 
complaint.27  An example of a substantiated complaint with a deficiency 
includes an ASCs being cited for a standard-level deficiency in infection 
control when State surveyors confirmed that it was not mopping the 
surgical suites after each patient.  A more serious example is State 
surveyors citing an ASC for numerous condition-level deficiencies when 
they confirmed that it failed to properly assess patients pre-operatively, did 
not have medical records for some patients, and did not follow its own 
procedures, among other problems. 
States largely appeared to investigate the second most serious type of 
complaintsthose categorized as non-immediate jeopardy-highwithin 
45 days, as required.  Of the 206 complaints in this category, States 
investigated at least 90 percent (185 complaints) on time (see Exhibit 11).  
States were late in investigating at least 6 percent (12 complaints).  We 
cannot determine from the data whether the remaining 4 percent 
(nine complaints) were investigated within the required 45-day timeframe.  
See Appendix C-2 for the total number of the most serious complaints that 
were investigated late per State from FY 2013 through FY 2017.  
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   11 
OEI-01-15-00400  Data limitations prevent us from determining definitively how often States 
met requirements to investigate the most serious complaintsimmediate 
jeopardywithin 2 days.  Of the 60 total immediate jeopardy complaints, 
States investigated at least 72 percent (43 complaints) on time and at least 
12 percent (7 complaints) late.  We cannot determine whether the remaining 
17 percent (10 complaints) were investigated on time (see Exhibit 11). 
 
Exhibit 11:  Between FY 2013 and FY 2017, States largely appeared to 
investigate the most serious complaints timely. 
  Non-Immediate Jeopardy - High:   Immediate Jeopardy: 
Must be investigated within  Must be investigated within 
45 calendar days  2 calendar days* 
On time  185 (90 percent)  43 (72 percent) 
Late   12 (6 percent)  7 (12 percent) 
Unknown  9 (4 percent)  10 (17 percent) 
 
* In this column, the percentages sum to 101 percent because of rounding. 
Source:  OIG analysis of ACTS data, 2019. 
 
 
 
   
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   12 
OEI-01-15-00400   
CONCLUSION 
State agencies play critical roles in ensuring the health and safety of 
Medicare beneficiaries who receive medical procedures, including invasive 
surgeries, from ASCs.  These roles include conducting certification surveys 
and assessing and investigating complaints.  Periodic surveys are 
an essential tool for ensuring that ASCs meet the minimum standards for 
health and safety.  CMS requires that States survey at least 25 percent of 
nondeemed ASCs each year and that no more than 6 years elapse between 
surveys for each ASC.  Most States met or came close to meeting these 
minimum requirements.  However, States cited deficiencies at about 
three-quarters of nondeemed ASCs in their most recent surveys and almost 
a quarter of ASCs had serious (condition-level) deficiencies.  Deficiencies 
were most frequently related to standards for infection control.  These 
findings underscore the importance of timely surveys so that deficiencies do 
not go unaddressed even longer.  
Although States received complaints about relatively few ASCs each year 
(fewer than 4 percent), States categorized a rising proportion of those 
complaints as serious (i.e., immediate jeopardy or non-immediate jeopardy 
high).  States appear to be generally meeting requirements to investigate 
the second most serious type of complaint (non-immediate jeopardy high) 
within 45 days.  However, States did not meet the 2-day requirement for 
investigating the most serious type of complaints (immediate jeopardy) 
complaints for at least 12 percent, and possibly as many as 28 percent, of 
these complaints.  The data limitations that prevented us from determining 
timeliness more precisely are also concerning, as CMS needs to be able to 
oversee and enforce timeliness requirements.   
CMS has made progress in strengthening oversight of ASCs and addressing 
vulnerabilities previously identified by OIG and GAO, and more can be 
done.  Meeting CMSs requirement for States to annually survey 25 percent 
of nondeemed ASCs deserves attention because of the extended time 
frame6 yearsof CMSs other requirement.  That 6-year timespan allows 
ASCs the potential to transition in and out of compliance, or worse, remain 
out of compliance for substantial amounts of time.  The results of this new 
analysis can support CMS in further strengthening its oversight, particularly 
of the few States that are falling short of meeting its requirements.  It can 
also help CMS focus on ASCs recurring challenges in meeting health and 
safety requirements, especially for infection control.   
 
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   13 
OEI-01-15-00400  METHODOLOGY  
Scope 
This data brief examines the extent to which Medicare investigated 
complaints about ASCs between FY 2013 and FY 2017; cited deficiencies in 
certification surveys conducted between 1992 and 2018; and met the 
following requirements for certification surveys: (1) surveying a minimum of 
25 percent of nondeemed ASCs per State in FY 2017 (CMSs Tier 2 
requirement); and (2) ensuring that 100 percent of ASC were surveyed in the 
6-year time period between FY 2012 and FY 2017 (CMSs Tier 3 
requirement). 
Methods 
We relied on three sources for this data brief:  State ASC certification survey 
records entered into the Certification and Survey Provider Enhanced 
Reporting (CASPER) system; CMSs Accrediting Organization System for 
Storing User Recorded Experiences (ASSURE) system; and data on 
complaints from the ASPEN [Automated Survey Processing Environment] 
Complaints Tracking System (ACTS) system. 
CASPER Data 
CMS provided us with data from CASPER, including records from 50 States 
and the District of Columbia.  We excluded ASC data from Guam, 
Puerto Rico, and the Virgin Islands in our analysis.     
We limited State certification analyses to health surveys for active ASCs, 
which we defined as ASCs that were still providing services at the time CMS 
provided us with CASPER data.  We primarily used the deemed status 
information in ASSURE to determine whether an ASC was deemed.  
However, if the ASC was listed in ASSURE as both deemed and nondeemed 
or if it was not listed in ASSURE, we used the deemed status information in 
CASPER to determine its status.  This gave us a final dataset that included 
3,735 nondeemed ASCs and 1,851 deemed ASCs.  Vermont did not have any 
nondeemed ASCs at the time of our analysis. 
For analyses assessing the percentage of ASCs that States surveyed in 
FY 2017 and the 6-year period between FY 2012 and FY 2017, our 
denominator consisted of all nonterminated ASCs with a begin service 
date earlier than October 1, 2016.  
We analyzed these data to determine national and State-level ASC 
certification survey trends.  We calculated: (1) the percentage of ASCs 
surveyed in FY 2017; (2) the percentage of ASCs surveyed during FY 2012 to 
FY 2017; (3) the mean deficiencies per State in the most recent certification 
survey; (4) the percentage of ASCs cited with deficiencies, including broken 
down by CfC, in ASCs most recent surveys; (5) mean number of deficiencies 
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   14 
OEI-01-15-00400  per survey between FY 2013 and FY 2017; and (6) the percentage of CfC 
deficiencies within total deficiencies between FY 2013 and FY 2017. 
ACTS Data 
CMS provided us with data on all deemed and nondeemed ASC complaints 
from FY 2013 through FY 2017.  Our final dataset included 2,904 records 
from 45 States.  (Hawaii, Montana, Nebraska, New Mexico, Vermont, and 
the District of Columbia did not have any complaints.)  Complaints can 
include multiple allegations; each record represents one allegation. 
We analyzed these data to determine national and State trends for ASC 
complaints between FY 2013 and FY 2017.  We calculated (1) the number of 
ASC complaints that States received; (2) the percentage of complaints that 
States prioritized as Immediate Jeopardy and Non-Immediate Jeopardy-
High; (3) the percentage of Immediate Jeopardy and Non-Immediate 
Jeopardy-High complaints that States investigated onsite within required 
timeframes; and (4) the percentage of Immediate Jeopardy and Non-
Immediate Jeopardy-High complaints that States substantiated.  
To determine whether States investigated complaints within required 
timeframes, we excluded weekends and Federal holidays and calculated the 
number of days that elapsed between the complaint receipt date (or, for 
deemed ASCs, the CMS regional office approval date) and the onsite 
investigation date.  We did not exclude State-only holidays from our 
analysis. 
Limitations 
We did not assess the extent to which the data in CASPER, ASSURE, or ACTS 
are complete.  We also did not independently verify the accuracy of the 
records.  We based our analysis on CASPER, ASSURE, and ACTS data and 
not on information collected directly from States.  
 
Standards  We conducted this study in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency. 
 
   
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   15 
OEI-01-15-00400  APPENDIX A: Ambulatory Surgery Centers, CMS Survey 
Conditions for Coverage* 
 
416.40   
Compliance with  The ASC must comply with State licensure requirements. 
State Licensure Law 
 
416.41  The ASC must have a governing body that assumes full legal responsibility for 
Governing Body   determining, implementing, and monitoring policies governing the ASCs total 
and Management  operation.  The governing body has oversight and accountability for the quality 
assessment and performance improvement program, ensures that facility policies 
and programs are administered so as to provide quality health care in a safe 
environment, and develops and maintains a disaster preparedness plan. 
 
 
416.42  Surgical procedures must be performed in a safe manner by qualified physicians who 
Surgical Services  have been granted clinical privileges by the governing body of the ASC in 
accordance with approved policies and procedures of the ASC. 
 
416.43  The ASC must develop, implement, and maintain an ongoing, data-driven quality 
Quality Assessment  assessment and performance improvement (QAPI) program. 
and Performance 
Improvement 
 
416.44  The ASC must have a safe and sanitary environment, properly constructed, equipped, 
Environment  and maintained to protect the health and safety of patients. 
 
416.45  The medical staff of the ASC must be accountable to the governing body. 
Medical Staff 
 
416.46  The nursing services of the ASC must be directed and staffed to assure that the 
Nursing Service  nursing needs of all patients are met. 
 
416.47  The ASC must maintain complete, comprehensive, and accurate medical records to 
Medical Records  ensure adequate patient care. 
 
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   16 
OEI-01-15-00400   
416.48  The ASC must provide drugs and biologicals in a safe and effective manner, in 
Pharmaceutical  accordance with accepted professional practice, and under the direction of an 
Services  individual designated responsible for pharmaceutical services. 
 
416.49  (a) Standard:  Laboratory services. If the ASC performs laboratory services, it must 
Laboratory and  meet the requirements of [42 CFR Part 493].  If the ASC does not provide its own 
Radiologic Services  laboratory services, it must have procedures for obtaining routine and 
emergency laboratory services from a certified laboratory in accordance with 
[42 CFR Part 493].  The referral laboratory must be certified in the appropriate 
specialties and subspecialties of service to perform the referred tests in 
accordance with the requirements of [42 CFR Part 493]. 
 
(b) Standard:  (1) Radiological services, Radiological services may only be provided 
when integral to procedures offered by the ASC and must meet requirements 
specified in 482.26(b), (c)(2), and (d)(2) of [42 CFR].  (2) If radiologic services are 
utilized, the governing body must appoint an individual qualified in accordance 
with State law and ASC policies who is responsible for assuring all radiologic 
services are provided in accordance with the requirements of this section. 
 
 
416.50  The ASC must inform the patient or the patients representative or surrogate of the 
Patient Rights  patients rights and must protect and promote the exercise of these rights, as set 
forth in this section.  The ASC must also post the written notice of patient rights in a 
place or places within the ASC likely to be noticed by patients waiting for treatment 
or by the patients representative or surrogate, if applicable. 
 
416.51  The ASC must maintain an infection control program that seeks to minimize 
Infection Control  infections and communicable diseases. 
 
416.52  The ASC must ensure each patient has the appropriate pre-surgical and post-surgical 
Patient Admission,  assessments completed and that all elements of the discharge requirements are 
Assessment, and  complete. 
Discharge 
 
416.54  The ASC must comply with all applicable Federal, State, and local emergency 
Emergency  preparedness requirements. The ASC must establish and maintain an emergency 
Preparedness  preparedness program that meets the requirements of this section. 
 
 
* Description from 42 CFR  416.40-416.54. 
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   17 
OEI-01-15-00400  APPENDIX B: Number and Percentage of ASCs Surveyed 
per State, Fiscal Years 2017 and 2011 Through 2017 
Exhibit B:  Total Active, Nondeemed ASCs Surveyed (Certification Survey) in FY 2017 and Between 
10/1/2011 and 9/30/2017, per State 
FY 2017  10/1/2011 to 9/30/2017 
(CMS Tier 2 requirement**)  (CMS Tier 3 requirement***) 
Total     
number of  ASCs  Percentage  ASCs  Percentage 
  ASCs*  surveyed   surveyed   surveyed   surveyed  
Alabama  26  9  35%  26  100% 
Alaska  11  2  18%  10  91% 
Arizona  104  33  32%  101  97% 
Arkansas  52  13  25%  52  100% 
California  414  75  18%  396  96% 
Colorado  85  12  14%  83  98% 
Connecticut  42  14  33%  42  100% 
Delaware  12  3  25%  12  100% 
District of Columbia   3  1   33%  3  100% 
Florida  293  89  30%  286  98% 
Georgia  238  68  29%  232  97% 
Hawaii  14  0  0%  9  64% 
Idaho  29  8  28%  29  100% 
Illinois  78  21  27%  76  97% 
Indiana  81  21  26%  79  98% 
Iowa  9  3  33%  9  100% 
Kansas  52  13  25%  52  100% 
Kentucky  31  7  23%  31  100% 
Louisiana  63  16  25%  63  100% 
Maine  13  5  38%  13  100% 
Maryland  293  138  47%  293  100% 
Massachusetts  30  6  20%  28  93% 
Michigan  56  14  25%  54  96% 
Minnesota  47  15  32%  47  100% 
Mississippi  54  13  24%  53  98% 
Missouri  80  22  28%  78  98% 
Montana  16  4  25%  15  94% 
Nebraska  37  9  24%  36  97% 
Nevada  44  4  9%  21  48% 
New Hampshire  17  4  24%  17  100% 
New Jersey  145  12  8%  123  85% 
New Mexico  9  4  44%  9  100% 
New York  41  7  17%  38  93% 
North Carolina  88  21  24%  63  72% 
 
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   18 
OEI-01-15-00400  Exhibit B (continued):   Total Active, Nondeemed ASCs Surveyed (Certification Survey) in FY 2017 
and Between 10/1/2011 and 9/30/2017, per State 
 
  FY 2017   10/1/2011 to 9/30/2017 
 
(CMS Tier 2 requirement**)  (CMS Tier 3 requirement***) 
Total 
number of  ASCs  Percentage  ASCs  Percentage 
  ASCs*   surveyed   surveyed   surveyed   surveyed  
North Dakota   9  3  33%  9  100% 
Ohio  102   33  32%  101  99% 
Oklahoma   33  9  27%  33  100% 
Oregon  66  19   29%  65  98% 
Pennsylvania  216   62  29%  214  99% 
Rhode Island   7  0   0%  7  100% 
South Carolina  56  17  30%  56  100% 
South  Dakota  16   4   25%  16   100% 
Tennessee   124   32  26%  122   98% 
Texas  225   76  34%  218   97% 
Utah  31  10   32%  30  97% 
Vermont  0  N/A   N/A   N/A   N/A  
Virginia  35  10   29%  34  97% 
Washington   144  38   26%  141  98% 
West Virginia  8  3  38%  8  100% 
Wisconsin   28  4  14%   28  100% 
Wyoming   15   5  33%  14   93% 
All States  3,722   1,011  27%   3,575   96% 
 
*  Total number of ASCs active during all of FY 2017. 
** CMS requires States to survey 25 percent of nondeemed ASCs per year. 
*** CMS requires States to survey individual nondeemed ASCs at a minimum of every 6 years. 
 Red text indicates that the State was noncompliant with the applicable Tier requirement  by a clear margin.  For 
the Tier 2 requirement, we considered this to be missing the 25-percent mark by two or more surveys.  For the 
Tier 3 requirement, we considered this to be surveying fewer than 90 percent of ASCs.  
  Rhode Island and Washington, DC each have seven or fewer ASCs.  To meet the Tier 2  requirement, according  
to the FY 2017 CMS Mission and Priority document, States with only 7 or fewer ASCs must survey at least 1 ASC 
unless all nondeemed ASCs were surveyed within the prior two years.  Further analysis by OIG indicates that 
Rhode Island did not meet this requirement.  
 
 
   
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   19 
OEI-01-15-00400   APPENDIX C:  Trends in ASC Complaints by State, Fiscal 
Years 2013 Through 2017 
Exhibit C-1:  Total Number of Complaints Received by States, FYs 2013 Through 2017 
 
Total number of complaints received 
  FY 2013  FY 2014  FY 2015  FY 2016  FY 2017 
Alabama  1  0  0  0  0 
Alaska  2  0  0  0  1 
Arizona  6  8  3  9  9 
Arkansas  2  3  2  2  1 
California  21  37  35  37  26 
Colorado  3  3  4  3  1 
Connecticut  0  0  0  0  0 
Delaware  0  1  0  0  2 
District of Columbia  0  0  0  0  0 
Florida  15  25  14  7  14 
Georgia  5  7  7  5  8 
Hawaii  0  0  0  0  0 
Idaho  1  1  1  1  1 
Illinois  0  3  5  10  6 
Indiana  4  2  3  2  3 
Iowa  0  0  0  0  1 
Kansas  2  3  2  3  2 
Kentucky  2  0  0  1  1 
Louisiana  3  2  1  0  1 
Maine  3  1  0  0  0 
Maryland  8  16  16  11  12 
Massachusetts  0  1  1  0  1 
Michigan  7  3  3  3  3 
Minnesota  2  2  0  0  3 
Mississippi  0  0  0  0  0 
Missouri  5  7  2  5  7 
Montana  0  0  0  1  0 
Nebraska  0  0  1  0  0 
Nevada  0  0  1  0  0 
New Hampshire  0  0  1  0  1 
New Jersey  13  14  8  13  5 
New Mexico  0  0  0  0  0 
New York  4  2  6  7  4 
North Carolina  3  5  4  1  2 
North Dakota  0  1  0  0  0 
Ohio  5  2  1  2  3 
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   20 
OEI-01-15-00400   
Exhibit C-1 (continued):  Total Number of Complaints Received by States, FYs 2013 Through 2017 
 
Total number of complaints 
 
  FY 2013  FY 2014  FY 2015  FY 2016  FY 2017 
Oklahoma  0  1  1  1  2 
Oregon  0  3  1  1  4 
Pennsylvania  4  1  1  4  3 
Rhode Island  1  0  0  0  0 
South Carolina  0  0  1  0  0 
South Dakota  0  1  0  0  0 
Tennessee  0  2  0  3  1 
Texas  5  16  11  6  10 
Utah  0  0  0  1  2 
Vermont  0  0  0  0  0 
Virginia  0  1  1  1  1 
Washington  1  5  2  4  1 
West Virginia  0  0  2  0  0 
Wisconsin  1  4  1  3  2 
Wyoming  1  3  0  0  3 
Annual Total  130  186  142  147  147 
 
 
   
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   21 
OEI-01-15-00400   
Exhibit C-2:  Total Number of Most Serious Complaints Investigated Late by State, Complaints 
Received FYs 2013 Through 2017 
  FY 2013  FY 2014  FY 2015  FY 2016  FY 2017 
Arizona  2      2   
California        2   
Georgia        1   
Illinois      2  1   
New York      1     
North Carolina    1       
Tennessee    2    3   
Texas       1    1 
     Total   2  3  4  9  1 
           
 
   
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   22 
OEI-01-15-00400   
ACKNOWLEDGMENTS 
Sarah Hijaz served as the lead analyst.  Others in the Office of Evaluation 
and Inspections who conducted the study include Kim Ruppert and Jesse 
Valente.  Office of Evaluation and Inspections staff who provided support 
include Kevin Farber, Christine Moritz, and Michael Novello.  
We would like to acknowledge the contributions of other Office of Inspector 
General Staff, including Berivan Demir Neubert. 
This report was prepared under the direction of Joyce Greenleaf, Regional 
Inspector General for Evaluation and Inspections in the Boston regional 
office, and Danielle Fletcher and Kenneth Price, Deputy Regional Inspectors 
General.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.  
Medicares Oversight of Ambulatory Surgical Centers: A Data Brief   23 
OEI-01-15-00400  ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public 
Law 95-452, as amended, is to protect the integrity of the Department of 
Health and Human Services (HHS) programs, as well as the health and 
welfare of beneficiaries served by those programs.  This statutory mission is 
carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit  The Office of Audit Services (OAS) provides auditing services for HHS, either 
by conducting audits with its own audit resources or by overseeing audit 
Services 
work done by others.  Audits examine the performance of HHS programs 
and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, 
abuse, and mismanagement and promote economy and efficiency 
throughout HHS. 
Office of Evaluation  The Office of Evaluation and Inspections (OEI) conducts national evaluations 
to provide HHS, Congress, and the public with timely, useful, and reliable 
and Inspections 
information on significant issues.  These evaluations focus on preventing 
fraud, waste, or abuse and promoting economy, efficiency, and 
effectiveness of departmental programs.  To promote impact, OEI reports 
also present practical recommendations for improving program operations.   
Office of  The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, 
Investigations 
operations, and beneficiaries.  With investigators working in all 50 States 
and the District of Columbia, OI utilizes its resources by actively 
coordinating with the Department of Justice and other Federal, State, and 
local law enforcement authorities.  The investigative efforts of OI often lead 
to criminal convictions, administrative sanctions, and/or civil monetary 
penalties. 
Office of Counsel to  The Office of Counsel to the Inspector General (OCIG) provides general 
legal services to OIG, rendering advice and opinions on HHS programs and 
the Inspector 
operations and providing all legal support for OIGs internal operations.  
General 
OCIG represents OIG in all civil and administrative fraud and abuse cases 
involving HHS programs, including False Claims Act, program exclusion, and 
civil monetary penalty cases.  In connection with these cases, OCIG also 
negotiates and monitors corporate integrity agreements.  OCIG renders 
advisory opinions, issues compliance program guidance, publishes fraud 
alerts, and provides other guidance to the health care industry concerning 
the anti-kickback statute and other OIG enforcement authorities. 
   
   
ENDNOTES 
 
1 MedPAC, Report to the Congress: Medicare Payment Policy, ch. 5, Ambulatory Surgical Center Services, 
March 2018. 
2 MedPAC, Report to the Congress: Medicare Payment Policy, ch. 5, Ambulatory Surgical Center Services, 
March 2019. 
3 Ibid. 
4 OIG, Quality Oversight of Ambulatory Surgical Centers: A System in Neglect, OEI-01-00-00450, February 
2002.   
5 OIG, Quality Oversight of Ambulatory Surgical Centers: The Role of Certification and Accreditation, 
OEI-01-00-00451, February 2002. 
6 OIG, Quality Oversight of Ambulatory Surgical Centers: Holding State Agencies and Accreditors 
Accountable, OEI-01-00-00452, February 2002.   
7 Jennifer Steinhauer, 77 New Cases of Hepatitis Are Identified in Las Vegas, The New York Times, May 9, 
2008.   
8 Kalhan Rosenblatt, More than 3,000 patients at New Jersey surgery center possibly exposed to HIV, 
hepatitis, U.S. News, December 25, 2018.   
9 42 CFR  416.2 and CMSs State Operations Manual, Pub. No. 100-07, Appendix L, Guidance for 
Surveyors: Ambulatory Surgical Centers, Part II,  416.2, Tag Q-0002. 
10 42 CFR  416.173 (requiring CMS to publish annually the list of covered surgical procedures for ASCs).  
Medicare covers 3,500 services provided in ASCs. 
11 MedPAC, Report to the Congress: Medicare Payment Policy, ch. 5, Ambulatory Surgical Center Services, 
March 2019. 
12 42 CFR pt. 416, subpt. CSpecific Conditions for Coverage. 
13 42 CFR  416.26(b)(1) and 488.12(a)(1). 
14 42 CFR  416.26(a) and 488.4(a).  See also CMS, FY 2017 Report to Congress: Review of Medicares 
Program Oversight of Accrediting Organizations (AOs) and the Clinical Laboratory Improvement 
Amendments of 1988 Validation Program.  Accessed at https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO19-01-RTC.pdf on April 1, 2019. 
15 CMS, Admin Info: 18-01-ALL REVISED 10.27.2017: FY2017 Mission & Priority Document-Action.  See also 
42 CFR  488.20(a) and (b).   
16 42 CFR  488.26.  CMS, State Operations Manual, Appendix L, Guidance for Surveyors: Ambulatory 
Surgical Centers, Part I, Task 4.  
17 CMS, State Operations Manual, ch. 5, Complaint Procedures,  5010.   
18 CMS, State Operations Manual, ch. 5, Complaint Procedures,  5075.1, 5075.2, 5075.3, 5075.4, and 
5075.9. 
19 Ibid.,  5100.1.  For deemed ASCs, a State must receive authorization from the CMS regional office before 
the State conducts a complaint investigation. 
20 OIG, Quality Oversight of Ambulatory Surgical Centers: A System in Neglect, OEI-01-00-00450, February 
2002.   
 
   
21 OIG, Quality Oversight of Ambulatory Surgical Centers: The Role of Certification and Accreditation, 
OEI-01-00-00451, February 2002. 
22 OIG, Quality Oversight of Ambulatory Surgical Centers: Holding State Agencies and Accreditors 
Accountable, OEI-01-00-00452, February 2002.   
23 GAO, Health-Care-Associated Infections:  HHS Action Needed to Obtain Nationally Representative Data 
on Risks in Ambulatory Surgical Centers, GAO-09-213, February 2009.  
24 Due to data limitations, we are unable to assess how States met this requirement over time.  
25 In our analysis of deficiency citations in State certification surveys, we conducted both mean and median 
calculations.  As part of this analysis, we determined that the deficiency citation data were not excessively 
influenced by extreme outliers.  Therefore, we are presenting only mean calculations in this report. 
26 In certain circumstances, a State may not investigate a complaint.  For example, a State may not 
investigate a complaint if the allegation does not involve Medicare/Medicaid participation requirements or 
if the State decides to refer the complainant to another agency or organization. 
27 CMS, State Operations Manual, Appendix L, Guidance for Surveyors: Ambulatory Surgical Centers, 
Part I (Rev. 137, 04-01-15).