In the past year, ASCs across the country have seen a notable acceleration in payer changes — from tighter reimbursement models and rising costs to an industrywide push toward bundled payments and value-based care.
The more than 28 leaders featured below are speaking at Becker’s 31th Annual: The Business and Operations of ASCs, Oct. 16-18, 2025, at the Swissotel in Chicago.
If you would like to join the event as a speaker, please contact Patsy Newitt at pnewitt@beckershealthcare.com.
As part of an ongoing series, Becker’s is connecting with healthcare leaders who will speak at the event to get their insight on thought-provoking questions within the industry.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: What’s been the biggest shift in your payer relationships/strategy in the last year — and how are you preparing for what’s coming next?
John Brady. CEO of Fox Valley Orthopedics (Allonquin, Ill): In the last 12 months or so we’ve seen a great deal of interest growing in the direct-to-employer/consumer marketplace. More employers and patients seem to be shopping out their care needs through digital marketplaces and upfront bundled pricing. Setting appropriate prices and ensuring there are no surprises post-purchase have been our focus as we test the waters with these new channels. 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. In addition, we are also applying greater attention to data management and analytics in our conversations with payers. The ambulatory level is considerably less expensive than the inpatient or [hospital outpatient department] levels of care, and the outcomes are at least equal to those settings, if not better. Through the incorporation of patient-reported outcome measures we intend to be more proactive in making our case to support our efforts when negotiating payer contracts.
Adam Bruggeman, MD. CEO and surgeon at Texas Spine Care Center (Shavano Park): This past year, we have spent more time looking into direct-to-employer bundling. As we look to the future, we will consider further negotiations on bundled payments and consideration for out-of-network models to better reflect the value that the practice brings, beyond inappropriately low fees for service payments.
Jennilee Caffey. Regional Administrator at Baylor Scott & White Sports Surgery Center at The Star (Frisco, Texas): As most of us have seen, payers continue to push for a shift in higher-acuity cases to the ASC due to rising costs of healthcare. Payers are renegotiating health system contracts to increase reimbursement when the procedure is performed in an ASC, but when compared to hospital costs, the payer sees a decrease in payments. From the ASC side, we are monitoring rising costs of products and maximizing contribution margin by having discussions with physicians to ensure clinical-appropriate products are used in the most cost-efficient way. As we continue to look ahead, we are working with vendors to create local agreements for rebates, high contract compliance and high/low structures.
Lori Callahan. Executive Director of Algonquin Road Surgery Center (Lake in the Hills, Ill.): Over the past year, the biggest shift in our payer relationships has been a more aggressive push toward bundled payments and site-of-service steering, particularly for high-volume orthopedic procedures like total joints and spine cases. Payers are increasingly focused on shifting these procedures to lower-cost settings like ASCs, which creates opportunities — but also new pressures.
In response, we’ve prioritized aligning with payers on transparent, evidence-based bundled pricing that reflects our efficiencies without compromising care quality. We’ve also strengthened our provider contract terms to reduce administrative friction and improve outcomes — two key metrics payers are watching closely.
Looking ahead, we’re preparing by deepening our investment in clinical and financial analytics, so we can clearly track and report on patient outcomes, complication rates and cost savings. We’re also staying close to evolving payer policies around prior auth[orization] reform and coverage changes for outpatient orthopedic procedures, particularly in total joint replacements. As the landscape continues to evolve, our strategy is to stay nimble, data-driven and proactive in demonstrating the value orthopedic ASCs bring to both patients and payers
Janet Carlson. Vice President of Ambulatory Surgery Centers at Commonwealth Pain and Spine (Louisville, Ky.): The biggest emphasis in our payer strategy has been to continue to build strong relationships with ongoing communication and transparency with payers. Our ASC platform offers a significant cost savings opportunity for payers and patients; we welcome the opportunity to share quality outcomes and patient satisfaction scores to demonstrate our partnership in reducing the traditionally high cost of surgical care. We are also mindful of the need to establish and maintain a clear plan for negotiating ASC rates, considering both on-cycle and off-cycle negotiations with payers. With the increasing shift of surgical care migrating to the ASC space, we have a roadmap for communicating our value proposition to ensure we are being reimbursed fairly for the excellent, reproducible care provided to our patients.
Harel Deutsch. Co-Director of Rush Spine Center (Chicago): The biggest shift I have seen over the past few years is the rise of Medicare Advantage Plans. The majority of patients who had Medicare, now have Medicare advantage plans. The Advantage plans actively work to deny surgeries. Certainly, we have had to devote more resources to appeal and counsel patients to switch back to Medicare. Currently, the trend for increasing Medicare Advantage plans is likely to continue. I have stopped doing some surgeries that are not covered by Medicare Advantage plans such as laminectomy with Coflex.
Jack Dillon. CEO of Anesthesia Practice Consultants (Grand Rapids, Mich.): 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. 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.
As insurance carriers become an increasingly outdated and unreliable method for financially supporting medical care, we are actively shifting toward alternative payment models. Many surgical centers and anesthesia practices are exploring direct-pay bundles and concierge anesthesia services that bypass third-party payers altogether. These models offer transparent pricing, faster payments, and fewer administrative burdens, ultimately allowing clinicians to focus more on quality and patient experience. By aligning with employers, direct-to-patient payment platforms, and value-based care initiatives, we’re not just adapting — we’re building a more sustainable and patient-centered future outside the constraints of traditional insurance.
Edward Dixon. Sterile Processing Manager at Surgery Center Mountain View (Calif.): 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. 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.
To keep up and stay ahead, we’ve been strengthening how we track and report performance. A major part of that is the rollout of Epic across the system, including at our ASC. This is a game-changer for us. It’s going to give us better visibility into the full episode of care — from pre-op to post-op — and help us provide cleaner, more consistent data to our payer partners.
Looking ahead, we know the shift toward risk-based contracts and performance-based reimbursement isn’t slowing down. So we’re investing in better care coordination, patient education and stronger follow-up practices. We’re also having more proactive conversations with our payer reps at the system level, making sure we’re aligned on expectations and outcomes.
Our focus is on being ready — not just for what’s coming, but for what patients need right now. That means staying flexible, staying informed and continuing to build systems that support high-quality, efficient care.
Karen Davidson, RN. Operations Consultant at Advanced Heart and Vascular Center of New Mexico (Carlsbad): We are a new cardiac ASC so all of our relationships are new, but I am amazed at how little you can reasonably interact with a human. I also thought insurance companies would be thrilled to negotiate with us, as we are a much lower-cost option than the hospital, but I am finding out that is not the case. In the coming year, we will attempt to negotiate with our insurance companies and will go into the negotiations with more data on quality and pricing.
Bruce Feldman. Administrator of the Bronx Ambulatory Surgery Center (New York City): The biggest shift in our payer relationships/strategy in the last year has revolved around reimbursement for implants especially for total joints. 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. Reimbursement from third-party payors simply has not been on par with this change in venue. The profit margins for ASC’s performing total joint replacement cases and complex orthopedic spine cases are steadily declining as many third-party payors are unwilling to “carve out implants” as part of their provider agreement contracts. Unfortunately, I think this trend is only going to continue. ASCs are going to really need to know their cost per case and be selective as to which cases make sense to do at their center.
Michael Gale. Administrative Director of Obici Ambulatory Surgery Center (Suffolk, Va.): Our payer contracts and contract negotiations are primarily managed by a corporate-based managed care department of a large acute care hospital system. There are significantly different reimbursement models involved —ASC facility reimbursement for place of service 24 versus [diagnosis-related group and ambulatory payment classification]-based reimbursement for acute care hospitals. And the nuances of those discussions, and how they may favor one side or another of those models, are critically important to understand.
I would imagine this bureaucratic structure is not uncommon for hospital systems with joint-venture ASCs. My challenge is to make sure that I monitor the impact of the contracts on my reimbursement and bring any issues to the attention of those corporate negotiators. Unfortunately, managing payer contractors after the fact with the goal of having an impact during the contract renewal of the following year is a game of catch-up. Make alliances within your own bureaucracy so that you have a voice when it counts the most. We’re all on the same team, after all. It has been my experience, traditionally negotiating payer contracts myself, that there are precious few people within any organization that truly understand the complexities of reimbursement. If you are one of those people, speak up. You are more valuable than you may realize.
Patrick Garman. Executive Administrator of Spartan Health Surgicenter (Monongahela, Pa.): The biggest shift in payer relations that I have seen in the Pittsburgh/southwest Pennsylvania market is higher annual patient deductibles with certain health plans and a very competitive landscape between my three largest payers (UPMC, Highmark BCBS and Aetna) for the Medicare Advantage and commercial insurance product lines.
Sean Gipson. Division CEO and President of Remedy Surgery Center (Hurst, Texas): The past year has seen a notable shift in health insurance payer relationships and strategy, particularly affecting ASCs. I’ll note some of the most impactful changes and how ASCs are preparing for what’s next.
In my opinion, the biggest shift has been with payers tightening utilization and reimbursement controls. In the last 12 months, the most significant trend has been more aggressive cost containment used by insurers through stricter prior authorization requirements, more narrow networks and direct contracting, pushing toward value-based care and site of service restrictions.
Stricter prior authorization requirements have seen a significant amount of attention in the last year. This has been accomplished by the expansion of prior authorization protocols, even for routine procedures. Another change has been with the implementation of AI tools by payers to deny claims faster or flag them for review.
Narrower networks and direct contracting have noted an increased use of narrow networks that favor large health systems or vertically integrated providers. A second trend has also been with a greater emphasis on direct-to-employer contracting and simply bypassing traditional carriers.
Another trend that has seen increased attention is the push toward value-based care. This is being accomplished with the offering of more bundled payments, shared savings models, and performance-based contracts. Secondly, we are seeing this with the overall migration from fee-for-service to outcome-driven metrics, even in the outpatient setting.
One last trend that has been noted in the past year has been with site-of-service restrictions. Insurance plans increasingly push procedures out of hospitals and into ASCs, but only selectively and at lower reimbursement rates. Some payers prefer the larger ASC chains or hospital-affiliated ASCs, putting independents at a disadvantage.
The natural next question is how ASCs prepare for these scenarios that will be here before we know it. The first preparation is with contract negotiation and diversification. We all need to act proactively by renegotiating our payer contracts to reflect inflation, supply costs, and labor pressures. The changes are time-consuming and not made easily with pay contract negotiations. A second preparation is to diversifying payor mix. Make sure to include more self-funded employer plans and Medicare Advantage — though both come with challenges.
Additionally, some ASCs are forming regional networks to increase negotiating leverage. If your ASC has this advantage, use it to negotiate higher rates obtainable strictly through volume plays.
Another preparation is, if you have not already done so, invest in RCM and authorization tools. This can be done by upgrading RCM platforms to handle denial management and prior auth automation. They take the time to train staff to preemptively address denial risks through better documentation and coding. It. Will be worth much more doing today rather than this time next year.
An additional tool to prepare your ASC is to take some time to explore value-based payment readiness. An ASC can do this by simply implementing a few important factors. One of which is tracking outcomes like infection rates, readmissions and patient satisfaction in preparation for value-based contracting. Many of us do this already, however, these numbers become very important in the VBC model. Secondly, some ambulatory surgery centers are joining accountable care organizations or clinically integrated networks to align with broader payment reform trends. Both tools will give you advantages over your competitor.
Employer and direct-to-consumer strategies are yet another way to prepare your center for the coming years trends. ASCs are developing direct employer relationships, offering bundled cash pricing or concierge surgical services. Additionally, ASCs are enhancing transparency and marketing directly to patients, especially for high-volume procedures like orthopedics or GI.
One last preparation for the advancing years trends in our market is to invest in technology and data analytics. Using these tools allows a center to leverage data analytics to measure outcomes, optimize scheduling, and benchmark performance. Secondly, centers are also using telehealth pre- and post-op assessments to reduce overhead and improve patient experiences effectively and efficiently. Annually, or even semiannually, it is well worth all our time to evaluate the market trends. From there we can recalibrate our systems to address the new trends to stay viable and competitive.
Tara Good-Young. CEO of Pediatric Dental Initiative of the North Coast (Windsor, Calif.): This past year, we focused on collecting, analyzing and leveraging payer reimbursement data to strengthen our negotiating position and prepare for future reimbursement challenges. Using verified data, we petitioned for improved rates while educating payers, as well as state and county representatives, on the critical role our center plays across 16 surrounding counties.
PDI Surgery Center, a charitable, nonprofit pediatric dental surgery center, provides essential care for children requiring treatment under general anesthesia, many of whom come from socioeconomically challenged backgrounds or have special needs. Despite lean operations, our costs consistently exceed reimbursement from state and county programs such as Medi-Cal, PHP, Denti-Cal and commercial Medi-Cal wrap-around plans, our most common payers.
To address these disparities, we collaborated with providers serving similar demographics to refine billing strategies and improve contract negotiations. We also deepened relationships with key payer representatives, transforming conversations into advocacy efforts that support sustainable reimbursement rates.
As the saying goes, “knowledge is power.” 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.
Adam Hornback. Administrator of North Texas Team Care Surgery Center (Mesquite): The biggest change that we are seeing is working with companies like HinkapinHealth that work with third-party payers and employer groups to bundle payments for cash surgeries. This brings the prices for employers down for their medical insurance. This part of the business is growing and they are growing throughout the nation to provide simplified billing for common surgery bundles.
Narasimhan Jagannathan, MD. Division Chief of Anesthesiology at Phoenix Children’s: For anesthesiologists at both ASCs and children’s hospitals, the biggest shift in payer relationships over the past year has been the increasing pressure to move toward value-based care models, often without adequate adjustment for the complexity of pediatric and high-acuity outpatient cases. We’ve seen a tightening of reimbursements, especially for out-of-network services and for procedures performed at ASCs, despite rising staffing and drug costs. 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. At children’s hospitals, we’re advocating for more appropriate risk adjustment in bundled or capitated payment models to reflect the unique needs of medically complex pediatric populations.
Omar Khokar, MD. Gastroenterologist of Illinois GastroHealth (Bloomington): This is ongoing, but the biggest change is collaborating with payers to demonstrate the value of care in the ASC setting. In terms of next steps, we need AI integration into “smart screening” strategies, and ultimately ASCs need to choose tighter payer alignment — choosing partners whose goals align with our clinical mission. That means saying no to low-performing contracts and yes to deeper partnerships with high-performing payers that reward value.
Earl Kilbride, MD. Surgeon at the Austin (Texas) Orthopedic Institute: Payer relationships are certainly a love/ hate phenomenon. As a small, single-specialty group, we try to diversify as much as possible. Going direct to the source has been beneficial. For example, we contract with a nationwide work comp provider. This helps buffer some of the payer control while adding to volume. We also contract with a federal agency for the same reasons. By doing good, fiscally responsible medicine, payers put our practice on a preferred list. In short, they are in control but there are things to mitigate some of these factors.
Helen Lowenwirth. Administrator at East Side Endoscopy (New York City): We are increasingly devoting more resources to provide patients with explanations of anticipated reimbursement and patient responsibility prior to dates of service while encouraging them to reach out to the payers in advance to confirm coverage limits.
Pradnya Mitroo, MD. President of Fresno (Calif.) Digestive Health: The biggest shift in our strategy with payers has been trying to renegotiate some of the contracts we have especially with our biggest commercial payors. Recently we were able to negotiate to have some of the plans start paying for the second procedure done at the same time (i.e. paying half-charge for the EGD performed at the same time as the colonoscopy). For the future, data-driven negotiation will be very important. We plan on using cost and outcome data to show insurers that we can deliver care more cost effectively than hospitals and with better quality and higher patient satisfaction.
Rick Ngo, MD. Founder and Surgeon at Texas Hernia & Surgical Specialist (Houston): I’d say the increase in focus on value-based care and contracting. Payers and surgical facilities are becoming more collaborative in developing safety/quality/satisfaction metrics that benefit all involved- the payors, the providers, the facilities, and most importantly, the patients.
Michael Powers. Administrator at Children’s West Surgery Center (Knoxville): In our recent payer fee negotiations, the use of business analytics was invaluable. Knowing the reimbursement for our most common procedures by payer allowed us to negotiate based upon parity. Standing firm on the lower paying insurance companies that we expect them to be comparable to their competitor’s rates for similar procedures. Then reviewing their contract offer in detail to ensure the parity is to the center’s best interest on the highest volume procedures. Sometimes it may appear that you are getting an increase, but it may not be on the higher volume cases thus not a true positive impact to your bottom line. In summary, knowing your business, surgical mix and payer rates per procedure is key followed by close review of any proposed contract language.
Amanda Ryan, DO. Interventional Cardiologist at the Advanced Heart and Vascular Center of New Mexico (Carlsbad): Our biggest shift in approaching payer contract negotiations includes engaging an actuarial analytics firm to help prepare for negotiations.
Vijay Sudheendra, MD. President of Narragansett Bay Anesthesia (Providence, R.I.):
Adoption of value-based and bundled payment models: There’s a clear movement away from traditional fee-for-service toward bundled payments, capitated contracts, and pay-for-performance agreements. These models are gaining traction as payers and providers both seek lower-cost and high-quality outpatient care, with ASCs well-positioned to deliver on these metrics.
Data-driven negotiations: ASCs are leveraging their own operational and clinical data to build compelling business cases for higher reimbursement rates. By demonstrating strong outcomes, patient satisfaction, and cost efficiency, ASCs are able to negotiate more favorable terms with payers.
Expansion of service lines: Many ASCs are expanding their procedure offerings and shifting more inpatient procedures to outpatient.
Maria Todd, PhD. Director of Business Development at Red Rocks Surgery Center (St. George, Utah): We are doing the following:
- Reexamining book of business to determine if a contract has been active, profitable and to what extent;
- If it has “sold/leased” our rates with other payers with whom we were already directly contracted at a higher rate, undermining our direct contract;
- If they have applied discounts to state specific fee schedules (work comp) and how it was characterized in the contract;
- If they are engaging in silent [preferred provider organization] discounts or aiding and abetting a bad actor;
- What their market penetration is for the past three years and if our payer mix is proportionally aligned; or if the contract should be terminated;
- Developing payer report cards by logo and product;
- Developing a brand agnostic app to do this with business software so we stay on top of it;
- Examining which are employers using the plans’ ASO product that are ERISA and unions that are self funded to determine if a direct with employer/union or “redirection” contract is an option.
Simply looking at fees and rates have never been enough, but we’ve reached a tipping point where this has become a necessity for strategic planning and tactical execution.
Anthony Tortolani, MD. Cardiothoracic Surgeon in New York City: The continued primary aim for insurance payers and private equity companies is profit, the goal of Medicare and Medicaid is to limit cost. Strategies to improve compliance, accuracy, efficiency with EMR and AI, increasing complexity of care and decreasing availability of caregivers since COVID are major factors in burnout and increased cost. Supply chain problems are a growing concern both in cost and efficiency. There is no one solution applicable to all hospitals and practitioners. Consultants may be of temporary help; the generic problems are universal and the solutions are local.
Strategic planning requires much integrated effort and time with key members of the Board of Trustees, senior administration and senior caregiver leadership to determine the feasible aims to best serve their community. The subsequent tactical planning is needed by responsible caregiver leadership to develop and ensure the plans are modified as needed and carried to conclusion. Hospitals and physician organizations of all types must partner to provide the care required by the patient community they serve.
As medical research and care develop, more care is provided in outpatient settings; less invasive, higher quality, better results, less complications, higher patient satisfaction, and less costly. This requires strategic planning responsible for each community’s needs. Also required is continuous tactical planning and its systems that respond to a changing environment eg. patient needs, supply issues, and staffing concerns. In-patient hospital care will require less beds; however, acuity and the needs of each patient’s care will be more complex and require more specialization but also more efficiently provided.
Like lawyers, teachers, clergy and we caregivers are professionals We are to provide for the needs of our communities. This is a time of change but most importantly a time of great progress. If we can adapt to best serve our communities, all will benefit.
LoAnn Vande Leest. Executive Director at Orthopaedic Associates of Wisconsin (Pewaukee): With the mantra of “work smarter, not harder” in mind, I’d say our biggest shift is in bundled agreements. These provide one upfront price for all costs on the day of surgery. These still go through intermediaries for referral to us and claim processing — but it opens us up to a bigger population of patients who are being steered by their employer, both large and small, to the best priced care. In preparation for this, now and going forward, we are acutely aware of our costs for staffing, supplies and implants, and know how each affects the bottom line.
Geogy Vennikandam. Chief Operating Officer of GI Partners of Illinois (Chicago): Over the past year, the biggest shift in our payer relationships has been a strategic pivot toward value-based care and proactive engagement with payers to align on outcomes that matter most to patients and employers alike. We’ve seen increased pressure on fee-for-service reimbursement and narrower networks, which has required us to be more data-driven and collaborative in how we demonstrate our clinical quality, efficiency, and cost containment.
In response, we’ve invested in infrastructure to improve care coordination, leverage data analytics for performance tracking, and standardize protocols across our growing network. We’re also building stronger direct lines of communication with payers, both locally and regionally, to jointly explore innovative reimbursement models, including episodic payments and shared savings arrangements.
Looking ahead, we’re preparing for continued consolidation and payer vertical integration by strengthening our scale and negotiating position — not just through size, but through demonstrable quality, operational consistency, and patient satisfaction. Our aim is to be a high-performing GI partner of choice for value-based contracts while remaining nimble and aligned with the evolving expectations of payers and employers alike.
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