New Jersey ASCs: Mandatory Reporting and Medical Director Agreement Requirements

Tina Segreto

The New Jersey Department of Health issued a memorandum to Ambulatory Surgical Centers (ASCs) on June 16, 2025, outlining new reporting requirements for medical directors, physician directors, physician directors of anesthesia, and directors of nursing services, as mandated by N.J.S.A. 26:2H-12(k). ASCs must submit this information by July 15, 2025, via email to AcuteCare@doh.nj.gov. The Department also plans to amend N.J.A.C. 8:43A to formally incorporate these requirements, signaling ongoing regulatory focus on ASC operations.

New Reporting Requirements

Key requirements ASCs should be aware of include:

  • By July 15, 2025: Submit names of your medical director, physician director, physician director of anesthesia (if applicable), and director of nursing to AcuteCare@doh.nj.gov (N.J.S.A. 26:2H-12(k)).
  • Ongoing: Report any changes in these roles within 30 days.
  • Medical Director Agreements: Ensure compliance with N.J.A.C. 8:43A, CMS standards (42 CFR §416), Federal Anti-Kickback Statute, Stark Law, and NJ Codey Law.

ASCs must act promptly to meet the July 15, 2025, reporting deadline and ensure ongoing compliance with the 30-day change notification requirement. The NJ Department of Health is amending N.J.A.C. 8:43A to strengthen oversight, with inspections likely to follow. Non-compliant agreements or missed deadlines could lead to penalties or operational risks.

This heightened regulatory posture reflects a growing focus on ensuring that ASCs are properly staffed, managed, and operating in accordance with state and federal healthcare standards. It also ensures that the Department has timely and accurate information about who is responsible for clinical oversight and compliance at each facility.

What ASCs Should Do Now

Given the short timeline and ongoing compliance obligations, ASCs should take immediate action:

  • Gather and submit the required information by the July 15, 2025, deadline.
  • Review current Medical Director and leadership agreements to ensure they meet both state and federal compliance standards.
  • Establish internal processes for tracking leadership changes and meeting the 30-day change reporting requirement.
  • Prepare for increased oversight and potential inspections as the Department updates its regulatory framework.

How Frier Levitt Can Help

Our team of experienced NJ ASC attorneys can help with reviewing and drafting Medical Director Agreements to meet state and federal regulations, ensure timely submission of required director information, develop processes to track and report director changes, and prepare your ASC for inspections and regulatory updates. Contact us today for assistance.