Denials, audits and delayed payments are accelerating across ASC, and leaders say payer behavior has become more aggressive, automated and less collaborative over the past year.
Five ASC executives joined Becker’s to discuss how they’re adapting, from tightening documentation and appeal workflows to deploying AI and elevating revenue cycle oversight to the C-suite.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: Have you seen an increase in denials, audits or delayed payments in the last year? If yes, what is your strategy to combat these obstacles?
Brian Bizub. CEO at Raleigh (N.C.) Orthopaedic: Yes. Over the past year, we have experienced approximately a 60% increase in down-coding, claim denials, bundled code issues, audits and delayed payments, particularly among Medicare Advantage plans. This trend is largely driven by payer automation and tighter post-payment reviews utilizing AI technology.
Historically, I have been a strong advocate for maintaining in-house revenue cycle management. However, I believe the time has come for private practices and ASCs to adopt end-to-end AI solutions. AI can provide both ambient and agentic capabilities to ensure claims are submitted cleanly using defined rule sets based on payer-specific denial behavior. It can also assist providers by ensuring documentation supports the codes billed, aligns with authorizations and automatically challenges denials using national and local payer policies, often without requiring human intervention.
While national organizations continue to advocate for physicians at the federal level, what is now needed is a grassroots effort to directly challenge payer practices. In my view, this has become a matter of AI versus AI by countering payer strategies that rely on slow pay, underpayments, and increased denials by improving first-pass clean claim rates.
Done correctly, this approach allows organizations to retain their most skilled RCM staff, potentially increase compensation, and ensure the organization is fully capturing the value of the services its providers deliver. Our organization just committed to one platform that has a full end-to-end AI technology suite that has been well established in the healthcare space and in the larger healthcare systems.
Phillip Blair. CEO of Surgery Center Services of America (Mesa, Ariz.): Yes, without a doubt. Denials and post-payment audits are up, especially around medical necessity and site-of-service. What’s changed is the tone: payers are less collaborative and more transactional than they were even a year ago.
Our response has been to get ahead of it. That means tighter surgeon documentation, fewer “we’ve always done it this way” assumptions and treating payer rules as something that changes constantly, because they do. We’re also pushing centers to take audits seriously at the leadership level, not just hand them to billing and hope for the best.
Centers that stay disciplined are surviving it. Centers that don’t are bleeding cash quietly.
Megan Friedman, DO. Medical Director of Pacific Coast Anesthesia Consultants (Los Angeles): Yes, we have seen a noticeable increase across all three — particularly denials and delayed payments related to medical necessity, site-of-care appropriateness and anesthesia involvement in lower-acuity cases.
Rather than simply absorbing that friction, we’ve taken a more proactive and structured approach:
- Tightening documentation standards to better support medical necessity at the front end
- Increasing anesthesia involvement in patient selection and case stratification before cases are scheduled
- Standardizing appeal workflows and tracking denial trends by payer to identify systemic issues
- Working more closely with hospital revenue cycle and ASC leadership to align clinical workflows with billing realities
The goal is not just to fight denials after the fact, but to reduce avoidable denials by designing clinical and operational processes that anticipate payer scrutiny.
Sandra Germany, BSN, RN. Administrator of Advanced Cardiovascular Specialists (Shreveport, La.): Yes, we have seen a significant increase in denials. So many insurance companies are outsourcing their decision making to third parties such as Carelon and Cohere and they have removed most, if not all, of the human element. For some, it has become almost impossible to get a human on the phone to help with anything, including claim questions. This is quickly becoming a patient safety issue. For example, we recently had a patient, post-heart catheterization, who was referred for bypass surgery. The insurance company denied the payment for the heart catheterization as, “not medically necessary.” Think about that, the patient had significant enough heart disease for bypass surgery but the actual heart catheterization that diagnosed the need for bypass surgery was not medically necessary? Another patient had his heart catheterization denied three times. Finally, it was approved, and he had a 99% blocked [left anterior descending artery]. Unfortunately, stories like this are becoming more of a rule than the exception. These insurance providers are making it so difficult to deal with them that reporting these incidents to our state insurance commissioner is quickly becoming our only avenue for help.
Andrew Tate. CEO of Graystone Eye (Hickory, N.C.): Yes, we’ve seen a clear increase in denials, audits, and payment delays over the past year, which mirrors what many physician-led organizations are experiencing. In response, we’ve taken a proactive, multi-layered approach: strengthening revenue cycle leadership, tightening documentation and coding alignment and partnering with specialized resources that help us manage payer relationships more effectively. These partnerships provide deeper visibility into payer-specific trends and enable earlier intervention, escalation, and appeal when issues arise. While diminishing reimbursement continues to create financial pressure, our focus has been on protecting operational stability without compromising care.
