As the healthcare landscape evolves, ASCs are navigating a complex payer environment characterized by rising costs, shifting reimbursement structures and increasing demands for data-driven value.
Here are five major payer trends disrupting the ASC industry today.
1. Rise in direct-to-employer and consumer models
ASCs are increasingly bypassing traditional insurance channels in favor of direct-to-employer and direct-to-consumer strategies.
John Brady, CEO of Fox Valley Orthopedics, told Becker’s there has been a growing interest in digital marketplaces offering bundled pricing, driven by employers and patients with high-deductible plans.
“Setting appropriate prices and ensuring there are no surprises post-purchase have been our focus as we test the waters with these new channels,” he said. “The early returns are positive, so we’re optimistic that with increases in those choosing high-deductible plans and employers looking to optimize their healthcare spending, we’ll be able to meet their needs in the “direct to” market.”
Other ASC leaders agree. Jack Dillon, CEO of Anesthesia Practice Consultants, told Becker’s that his company is shifting focus to alternative payment models, such as direct-pay bundles and concierge anesthesia services, as insurance carriers “become an increasingly outdated and unreliable method for financially supporting medical care.”
2. Accelerated shifts toward bundled payments
A universal theme among ASC leaders is the accelerating transition away from fee-for-service toward bundled and value-based payment models.
“One of the biggest shifts we’ve seen over the past year is a stronger push from payers toward value-based care and bundled payments,” Edward Dixon, sterile processing manager at Surgery Center Mountain View (Calif.), told Becker’s. “There’s a lot more focus on outcomes, efficiency, and transparency around costs — and that’s changing how we approach both our workflows and our data.”
Lori Callahan, executive director of Lake in the Hills, Ill.-based Algonquin Road Surgery Center, told Becker’s that payers are pushing orthopedic and high-acuity procedures into ASCs, but with a focus on outcomes, cost transparency and data reporting.
“In response, we’ve prioritized aligning with payers on transparent, evidence-based bundled pricing that reflects our efficiencies without compromising care quality,” she said. “We’ve also strengthened our provider contract terms to reduce administrative friction and improve outcomes — two key metrics payers are watching closely.”
3. Payer cost-containment strategies
From narrow networks to prior authorization expansion and AI-driven denials, payers are intensifying cost-containment efforts.
Sean Gipson, division CEO and president of Hurst, Texas-based Remedy Surgery Center, told Becker’s that“stricter prior authorization requirements, more narrow networks and direct contracting” are dominant disruptors.
Janet Carlson, vice president of ASCs at Louisvilled, Ky.-based Commonwealth Pain and Spine, emphasized the growing importance of proactive payer relationship management and rate negotiation, both on-cycle and off-cycle.
Mr. Dillon has seen the squeeze particularly with anesthesia reimbursements.
“The biggest shift in our payer relationships over the past year has been the accelerating trend of payers aggressively narrowing networks and unilaterally cutting reimbursement, particularly targeting anesthesia services,” he said. “We’re also seeing more frequent delays in contract negotiations, denials for medically necessary care and increased pressure to accept unfavorable in-network rates. These moves are often justified under the guise of cost containment, but they threaten practice sustainability and patient access to care.”
4. Increased focus on data-driven negotiation
Data is quickly becoming a primary currency in payer negotiations. From small practices to hospital-affiliated ASCs, leaders are using detailed analytics on procedure costs, outcomes and patient satisfaction to push for fair reimbursement.
“By leveraging data-driven insights, we equipped our payer representatives with verified statistics, empowering them to advocate for necessary rate adjustments and safeguard access to care,” Tara Good-Young, CEO of Windsor, Calif.-based Pediatric Dental Initiative of the North Coast, told Becker’s.
Maria Todd, director of business at St. George, Utah-based Red Rocks Surgery Center takes it a step further, developing payer report cards and tech tools to track contract behavior and profitability.
“Simply looking at fees and rates has never been enough,” she said. “But we’ve reached a tipping point where this has become a necessity for strategic planning and tactical execution.”
5. Growing disparities in pay for high-acuity and specialty care
As more complex cases migrate to ASCs, many administrators report that payer reimbursement hasn’t kept pace.
“As more and more higher-acuity level surgery cases migrate out of the hospital setting and into the ASC setting, we are faced with more costly supplies and instrumentation required to do these types of cases,” Bruce Feldman, administrator of New York City-based Bronx Ambulatory Surgery Center, told Becker’s. “Reimbursement from third-party payers simply has not been on par with this change in venue.”
Leaders are also seeing this issue in anesthesia care.
“We’ve seen a tightening of reimbursements, especially for out-of-network services and for procedures performed at ASCs, despite rising staffing and drug cost,” Narasimhan Jagannathan, MD, division chief of Anesthesiology at Phoenix Children’s, told Becker’s. “To prepare for what’s next, we’re focusing on building stronger data infrastructure to demonstrate the value we provide — particularly around patient safety, efficiency and outcomes.”
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