The ASM Miscount: Why Roughly 500 Cardiologists May Be on a Mandatory Payment List They Don't Belong On
Health Policy & Practice Economics
A new mandatory Medicare payment model for heart failure has a list problem, and the list determines who is financially exposed starting in 2027.
The Ambulatory Specialty Model, known as ASM, was finalized by the Centers for Medicare and Medicaid Services as part of the 2026 Medicare Physician Fee Schedule.
ASM is designed to hold general cardiologists financially accountable for the longitudinal, outpatient management of heart failure, alongside a parallel track for low back pain specialists.
The model deliberately excludes interventional cardiology, electrophysiology, and advanced heart failure and transplant specialists, restricting participation to general cardiology.
According to the American College of Cardiology, that exclusion criterion was not applied correctly when CMS generated its preliminary participant roster.
Society leadership has stated that roughly 500 of the approximately 2,600 cardiologists on the preliminary list were flagged as misclassified, including subspecialists CMS itself says should be exempt.
This matters because ASM is a two-sided risk model, meaning every included physician is exposed to both upside and downside payment adjustments on Medicare Part B claims.
Source: CMS ASM Model Overview Factsheet. Adjustments apply to all Part B allowed charges, not only heart-failure-related services, and the range may widen in later payment years.
What Went Wrong With the List
CMS built the preliminary ASM roster from historical Medicare claims, identifying physicians who treated at least 20 original Medicare beneficiaries with heart failure over a 12-month lookback period within a selected geographic area.
The intent, per CMS, was to capture general cardiology exclusively, since interventional, electrophysiology, and advanced heart failure colleagues already operate under different cost and referral patterns that the model isn't designed to evaluate.
Claims-based specialty tagging is imperfect, and a cardiologist who bills certain procedural or device codes can still carry a general cardiology taxonomy code in CMS's enrollment system.
That mismatch appears to be the root cause, and it means a physician's actual clinical focus may diverge from how CMS's claims algorithm classified them.
The ACC has formally raised these discrepancies with CMS and is pushing for a transparent, standing correction process rather than a one-time fix.
No such formal appeals mechanism exists yet, which is itself part of the advocacy ask.
Who Should Check the List, and How
Every general cardiologist who treats a meaningful outpatient heart failure panel under original Medicare should confirm their own status rather than assume they are uninvolved.
The preliminary ASM participant dataset is searchable by NPI on CMS's public data portal.
Physicians who believe they were included in error, particularly interventionalists, electrophysiologists, and advanced heart failure or transplant cardiologists, are urged to contact CMS directly at AmbulatorySpecialtyModel@cms.hhs.gov.
The final participant list is expected in late summer 2026, ahead of the model's January 1, 2027 launch.
Employed physicians, including those at large academic or hospital-affiliated systems, should also ask their division or department leadership whether group-level compensation formulas reference CMS Innovation Center model performance, since wRVU-based plans were not built with episode-based payment adjustments in mind.
What CMS Will Actually Measure
Once finalized, ASM evaluates each general cardiologist across four domains: quality, cost, care improvement activities, and interoperability, modeled on the existing MIPS Value Pathways framework.
Within quality, CMS has signaled that blood pressure control and adherence to guideline-directed medical therapy for reduced ejection fraction will be central measures.
That places a familiar drug bundle squarely under financial scrutiny: beta-blockers, renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists, and SGLT2 inhibitors.
Patient-reported outcome measures are also part of the model, which is a reporting workflow many general cardiology practices have not yet built or licensed.
| Specialty | ASM Status | Rationale |
|---|---|---|
| General cardiology | Included | Primary outpatient manager of chronic HF under Original Medicare |
| Interventional cardiology | Excluded | Procedure-driven cost and referral pattern, not longitudinal HF management |
| Electrophysiology | Excluded | Device and arrhythmia focus falls outside the model's HF episode design |
| Advanced HF / transplant cardiology | Excluded | Manages the highest-acuity HF subset the model was not designed to risk-adjust for |
The Guideline-Directed Therapy Bundle Under the Microscope
Because ASM's quality score leans on whether reduced-ejection-fraction patients are on appropriate therapy, documentation and prescribing patterns now carry direct payment consequences.
Among the four pillars, the angiotensin receptor-neprilysin inhibitor class has the most complex cost landscape for patients and practices to navigate.
Novartis (NYSE: NVS) markets the branded ARNI Entresto (sacubitril/valsartan), which lost patent exclusivity in 2025, opening the door to lower-cost generic sacubitril/valsartan alternatives.
Brand-name Entresto still lists at roughly $600 to $700 per 30-day supply at retail, while generic sacubitril/valsartan is now available for as little as $45 to $50 per month with a standard pharmacy discount card.
Medicare Part D beneficiaries also benefit from an Inflation Reduction Act negotiated price of approximately $295 per month for the brand product, effective 2026.
For practices building ASM-ready prescribing protocols, knowing the generic option exists is now a quality-and-cost lever, not just a patient-affordability conversation.
| Drug Class | Generic | Common Brand | Approx. Monthly Cost | Manufacturer |
|---|---|---|---|---|
| Beta-blocker | Carvedilol / metoprolol succinate | Coreg / Toprol-XL | $4–$15 (generic) | Multiple generic manufacturers |
| ACE inhibitor | Lisinopril | Zestril | $4–$10 (generic) | Multiple generic manufacturers |
| ARNI | Sacubitril/valsartan | Entresto | $45–$50 (generic) / $600–$700 (brand) | Novartis (NVS) |
| MRA | Spironolactone | Aldactone | $4–$12 (generic) | Multiple generic manufacturers |
A general cardiologist employed by an academic health system has historically managed roughly 150 Medicare patients with heart failure with reduced ejection fraction each year.
The physician learns their practice city is in a selected ASM region and assumes participation is automatic and unavoidable.
A search of the CMS participant dataset by NPI confirms inclusion, prompting the physician to audit current prescribing for the four-pillar guideline-directed therapy bundle.
The audit reveals several patients are still on legacy ACE inhibitor monotherapy without an ARNI or SGLT2 inhibitor trial, a gap that would directly lower the quality score once performance years begin.
The physician also confirms with division leadership whether the employer's wRVU compensation formula will pass through any ASM payment adjustment, since that detail is not standardized across institutions.
Why This Reaches Beyond the 500
Even cardiologists confident in their own classification should treat this episode as an early signal about ASM's operational maturity.
A claims-based algorithm mis-tagging 500 physicians on a first pass suggests the underlying attribution logic, the same logic that will assign patients and calculate cost benchmarks, is still being refined.
Practices in selected geographic areas have a narrow window before the late-summer 2026 final list to verify documentation, build PROM collection infrastructure, and confirm compensation-plan interactions with division leadership.
Roughly 500 cardiologists may be on a mandatory CMS payment list they don't belong on, and the correction window is open now, not after the final list ships in late summer 2026.
Every general cardiologist in a selected region should verify NPI status on the CMS participant dataset, confirm guideline-directed therapy documentation for HFrEF patients, and ask employer leadership how ASM adjustments interact with wRVU compensation.
References
- Centers for Medicare and Medicaid Services. ASM (Ambulatory Specialty Model) overview page.
- CMS Innovation Center. ASM Model Overview Factsheet (PDF).
- CMS. ASM Frequently Asked Questions.
- American College of Cardiology. Ambulatory Specialty Model for Heart Failure advocacy hub.
- CMS. ASM Participants dataset (searchable by NPI).
- GoodRx. Entresto (sacubitril/valsartan) pricing.
This article is intended for physician education on healthcare policy and practice economics, and does not constitute legal, financial, or compensation advice. Clinicians should confirm their individual ASM participation status directly with CMS and consult their institution's compliance and contracting offices regarding compensation-formula implications.
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