The anesthesia problem ASC leaders talk about is workforce. The one arriving next is payers.
Vijay Bachani, president and chief growth officer of Roslyn Heights, N.Y.-based New York Bariatric Group, told Becker’s insurers are starting to punish ASCs for the out-of-network anesthesia providers working inside them, including canceling the facility’s own contract.
“Payers are coming after ASCs that allow out-of-network providers, including anesthesia, sometimes by terminating the facility contract outright,” Mr. Bachani said. “Combined with the pressure from the No Surprises Act and [independent dispute resolution], that’s pushing everyone toward in-network arrangements, where facility subsidies are becoming table stakes. The weaker your payer mix, the more of the coverage cost you end up underwriting.”
Anesthesia has been among the specialties most disrupted by surprise billing protections, given how frequently anesthesiologists deliver services at in-network facilities under out-of-network contracts. The No Surprises Act’s independent dispute resolution process was designed to resolve those gaps, but the process itself has become a source of friction.
Antonio Hernandez Conte, MD, former president of the California Society of Anesthesiologists, previously told Becker’s, “the No Surprises Act remains a continual burden for anesthesia practices as insurers delay payments for up to 90 or 120 days even if anesthesia groups are successful in the arbitration dispute resolution process.”
The litigation is escalating alongside the frustration. In December, a group of 33 NorthStar anesthesia providers filed suit against Aetna and Cigna alleging $4.1 million in combined NSA underpayments, claiming the insurers either never paid or paid late without interest following IDR determinations that require payment within 30 days. The providers claim Cigna owes more than $2.3 million and Aetna more than $1.7 million. In March, the American Society of Anesthesiologists filed an amicus brief in the U.S. District Court for the Eastern District of Pennsylvania supporting NorthStar in a related lawsuit brought by UnitedHealthcare over the IDR process.
Commercial payers aren’t the only pressure. Stanford Plavin, MD, owner of Atlanta-based Oral Surgery Anesthesia Associates, told Becker’s stipend and revenue-guarantee arrangements are most common where government payers dominate.
“This especially holds true to practices that are heavily weighted towards Medicare and other government payers which hit anesthesia providers the hardest,” Dr. Plavin said.
The Medicare gap is significant. CMS reimbursement for anesthesia has fallen 5.5% since 2019 on a per-unit basis, even as CRNA salaries have risen 59% over the same period, according to Marit Health and AANA data. Maher Kodsy, MD, chair of the department of anesthesiology at University Hospitals Elyria, Ohio, Medical Center, put the structural problem in direct terms.
“As long as CMS continues to pay less than 20% of the provider’s actual compensation, ASCs will continue to subsidize anesthesia services,” Dr. Kodsy said. “ASCs do not receive the same governmental financial assistance as hospitals and healthcare systems nationwide. If they continue to offer subsidies for anesthesia services rendered, their profit margins will continue to decline.”
The share of ASCs paying anesthesia stipends has already jumped from 28% in 2024 to 44% in 2025, according to VMG Health, a trend that reflects the margin compression Dr. Kodsy describes. For centers with weak payer mix, that subsidy burden lands on whoever has the least contractual leverage.
Aaron Hayes, administrative director of North Pointe Surgery Center in Lancaster, Pa., argued ASCs should respond by negotiating total case economics rather than defending anesthesia as a standalone line item.
“Payers are evaluating total reimbursement, not necessarily the internal buckets we use between facility, professional, and anesthesia revenue,” Mr. Hayes said. “As contracts come up for renewal, the focus should be on improving total case economics rather than preserving arbitrary distinctions around where the anesthesia reimbursement sits.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.