How long do Certificate of Need approvals add to healthcare development timelines?

In most states, Certificate of Need (CON) approvals add 3–12 months to a healthcare project, and 12–24 months if the application is challenged or appealed; plan for 90–120 days of pre-filing preparation plus the state’s review and potential hearing schedule.

Why it matters

Timeline is critical. A 40,000 SF ambulatory surgery center projected to generate $2.0–$3.0 million in annual EBITDA forfeits roughly $165,000–$250,000 for every month opening is delayed. Meanwhile, construction inflation of 4–6% annually (0.3–0.5% per month) and interest carry on predevelopment spend compound the cost of waiting.

CON delays also disrupt strategic sequencing. Missing a market window can cede first-mover advantage to a competitor, force physicians to extend expiring leases, and push projects into tighter labor or materials markets that increase total project cost by 5–10%.

How it works

Most CON processes follow a predictable path: pre-application planning (60–120 days), submission, completeness review (2–4 weeks), staff review (60–120 days), public comment/hearing (as scheduled), decision (within 30 days of hearing), and potential appeal (3–12 months). Batch cycles in some states mean you can file only in designated windows, which can add 30–90 days if you miss one.

Expect 3–9 months for straightforward, uncontested projects like freestanding imaging or small bed relocations, and 9–12 months for higher-profile items like ASCs or hospital expansions. If a competitor requests a hearing or files an appeal, add 6–12 months, and if litigation follows, total duration can reach 18–24 months.

About 35 states and the District of Columbia require CON or similar review in 2025. Triggers vary by state but typically include new ASCs, bed increases, freestanding imaging (MRI/CT), new hospital services, and capital expenditure thresholds (often $5–$10 million, indexed in some states). Always confirm current statutes and agency guidance before scoping schedule.

Key considerations

Know your triggers and thresholds. Some states require CON only for specific service lines (e.g., MRI, cardiac cath), others for any capital project over a dollar threshold, and a few exempt hospital outpatient departments located on-campus. Structuring the project as provider-based or on-campus can, in some states, shorten review or avoid CON altogether.

Prepare a data-driven need case. Strong applications quantify unmet demand using population growth, disease prevalence, drive times, and current utilization versus state benchmarks, then tie capacity to specific physician FTEs and block schedules. Inconsistent volume projections or missing physician commitments are the most common reasons for challenge.

Anticipate opposition. Competitors can intervene, request hearings, and appeal decisions. Reduce risk by engaging community stakeholders early, documenting access benefits (e.g., Medicaid acceptance, charity care), and aligning the service mix with documented gaps rather than duplicative capacity.

Budget realistically. Filing fees can range from a flat $5,000–$50,000 to a percentage of project costs, while legal, strategy, and market analytics commonly total $150,000–$400,000 for a contested project. Carrying costs during delay—lost contribution margin plus escalation—often exceed $250,000 per month for larger ambulatory projects.

Actionable takeaway

Build a conservative plan: allocate 90–120 days for pre-filing preparation, 6–9 months for review, and a contingency of 6–12 months for potential challenges. Run site control, design development, and financing in parallel up to a defined “go/no-go” gate so you can accelerate when approved without overcommitting before risk clears.

If you need help structuring your schedule, data package, and stakeholder strategy, explore our healthcare real estate development and strategy services, review our services overview, or request a consultation. Bremner Real Estate partners with health systems to align real estate strategy with clinical performance and capital efficiency.

Which project types most often require a CON?

New or expanded ASCs, hospital bed additions, freestanding MRI/CT, cardiac cath labs, and certain behavioral health facilities commonly trigger CON review. Some states also review capital expenditures over a set threshold even if the service mix is unchanged.

Can we start design or buy equipment before CON approval?

You can advance planning and schematic design at risk, but avoid major procurement or construction mobilization until approval. Many states prohibit acquiring regulated equipment like MRI or committing to construction contracts before a CON decision, and early purchases can jeopardize the application.

How do we reduce the risk of a competitor challenge?

Anchor the application in verifiable need, include signed physician support, document access for Medicaid and self-pay patients, and engage community partners who can speak to gaps in care. Consistent, transparent projections and a right-sized scope reduce the appearance of unnecessary duplication, making challenges less likely to succeed.

Is it faster to pursue an on-campus, provider-based department instead of a freestanding site?

In some states, yes. Provider-based, on-campus projects may fall under different thresholds or exemptions and face less opposition, but reimbursement, space programming, and long-term flexibility differ. Model both options for timeline, CON exposure, revenue, and capital cost before deciding.

What should we budget for CON filing and related costs?

Plan $50,000–$100,000 for straightforward filings and $200,000–$500,000 for complex or contested projects, including market analysis, legal, and expert testimony. Add contingency for carrying costs: for projects targeting $2 million in annual EBITDA, each month of delay can cost $150,000–$200,000 in deferred margin plus construction escalation.