Relationships across the ASC ecosystem are under growing strain, but ASC leaders say payers are the clear pressure point.
Five executives joined Becker’s to discuss how denials, shifting policies and reimbursement pressure are reshaping how ASCs work with insurers, health systems and anesthesia partners.
Editor’s note: Responses have been edited lightly for clarity and length.
Question: Which relationship is under the most strain right now: payers, physicians, health system partners, anesthesia groups or vendors — and what’s causing it?
Brian Bizub. CEO at Raleigh (N.C.): Orthopaedics: Currently, the most strained relationship is with payers, particularly Medicare Advantage plans. This tension is driven by AI-driven down-coding and denials, delayed payments, post-payment audits, and inconsistent policy application, all of which shift financial and administrative burdens onto providers and ASCs, creating an increasingly adversarial environment.
Tensions are also rising with hospital systems as the IPO list nears elimination. The shortage of anesthesia providers is intensifying pressure, leading to higher compensation subsidies while reimbursement from payers decreases. Additionally, joint ventures and direct-employer contracting are creating friction, as hospitals may face challenges negotiating rates with payers when bundled, value-based programs set lower reimbursement through TPAs.
Phillip Blair. CEO of Surgery Center Services of America (Mesa, Ariz.): Payers, and it’s not close.
Rates are under pressure; policies change mid-year, and payment timelines keep stretching. Meanwhile, ASC costs haven’t gone down for labor, supplies, or compliance. That mismatch is forcing tough conversations.
The stronger ASCs are pushing back with data, narrowing networks when necessary, and being willing to walk away from bad contracts. The old mindset of “any contract is a good contract” just doesn’t work anymore.
Megan Friedman, DO. Medical Director of Pacific Coast Anesthesia Consultants (Los Angeles): The tension is being driven by a widening disconnect between the clinical complexity we are managing — particularly in ASCs and NORA settings — and how payers are redefining medical necessity and reimbursable anesthesia services.
Payers are pushing for narrower coverage, more denials, and lower unit reimbursement at the same time procedural volumes and patient acuity are rising. That misalignment creates operational and financial pressure not only for anesthesia groups, but for hospitals and ASCs trying to maintain safe, reliable access to care.
That said, we are seeing stronger alignment with physicians and health system partners as we navigate these challenges together — particularly around patient selection, coverage models, and redesigning care pathways in ways that preserve safety while adapting to reimbursement realities.
Sandra Germany, RN. Administrator of Advanced Cardiovascular Specialists (Shreveport, La.): Payers. Prior authorization burden is almost unsustainable, but I feel that is by design. More recently, many of these carriers have forced us to notify them of any interventional procedures on the same day it is performed in addition to the original procedure. For example, we have the prior authorization for a heart catheterization or a peripheral case and during the procedure it is determined that an intervention is needed. We then have to get that interventional auth on the same day as the procedure, adding another burden on the practice. To add insult to injury, some insurance providers have removed the ability to apply for a retro auth if one of these interventions is missed on the same day. This is in no way just related to Medicare Advantage plans, but they can’t be overlooked. I think we can say with certainty that Medicare Advantage plans have not been an advantage to most patients and have significantly impacted patient care.
Andrew Tate. CEO of Graystone Eye (Hickory, N.C.): Payer relationships are under the greatest strain. The challenge is less about clinical disagreement and more about increasing administrative burden, inconsistent policies, and continued downward pressure on reimbursement. These dynamics introduce friction that impacts physicians, staff, and ultimately the patient experience. Despite this, our priority remains unchanged: maintaining high-quality care, excellent outcomes, and a patient-centered experience. We’ve been intentional about insulating clinical teams from administrative complexity so they can stay focused on delivering the level of care our patients expect.
