From payer obstacles to operational pressures, five ASC leaders discuss the biggest frictions they’re facing.
Note: Responses were lightly edited.
Question: Where are you seeing the most friction in your practice? How are you approaching it?
Brian Gantwerker, MD. President at The Craniospinal Center of Los Angeles: The idea of friction to me is something that inhibits you from doing a good job or growing your business, and in medicine it’s physicians getting paid. The latest area of friction is insurance companies creating problems with essentially what has been laid out as the rules of the road, and they continue to try to employ tactics to claw back or otherwise underpay physicians. The latest instance was when I had to do a surgery on a patient that involved a vascular surgeon getting into the abdomen to place an artificial disc. In order to do that safely, you have to employ the services of an approach surgeon. But the insurance decided to send a letter and say I didn’t need the approach surgeon. What we’ve seen now is new levels of dishonesty and clawbacks from the insurers, and there’s a lot of problems right now with physicians getting paid. It’s going to lead to more and more issues with physicians staying independent and staying in-network.
The other thing that we found in terms of friction is the websites of the insurers remain Byzantine, and it’s becoming very hard to navigate. Let’s say a physician wants to drop an insurer. You have to send two or three emails to find out the right website address of where you can go and modify your contracts and then drop it. Even when you do that, there is no confirmation or receipt. So you could potentially go on for months thinking you’re out of network, and actually still be in network, which can lead to problems with patients, billing issues, potential allegations of fraud and all sorts of things that make you out to be the bad guy even when you’ve done the due diligence. You can have an order confirmation from the minute you buy something on Amazon. To not be able to have a confirmation from insurers I think is intentional.
Michael Gale. Administrative director at Obici Ambulatory Surgery Center (Suffolk, Va.): Requests for last-minute add-ons (defined as a surgical referral within 48 hours of the proposed DOS) are becoming more common. Friction is created when those add-on cases are lacking a complete medical record for clearance. For example, it brings an already tight timeline to a halt when something as basic as an H&P is missing or when there isn’t evidence of a cardiac clearance that a patient’s surgical history or chronic disease state would normally indicate as necessary. It takes patience and diplomacy from front-line staff, like my referral coordinators, PAT (Pre-Admissions Testing) RN’s and Medical Director to manage this dynamic. When the pressure to add a case is competing with the necessary time to clear a patient for surgery, the case may have to wait until the next available surgical date. I often have to remind our referral sources that this effort to accommodate is a courtesy and not an entitlement. This is the nature of outpatient surgery center scheduling.
Sean Gipson. CEO and Division president of ASCs at Remedy Surgery Center (Hurst, Texas): One of the most challenging times with our ASC practice today is the intersection of rising patient complexity and mounting operational pressure; all while reimbursement tightens.
The core challenge is that ASCs now see much of the following: Older, sicker patients with multiple chronic conditions, more complex procedures migrating from hospitals to outpatient settings, persistent workforce shortages, especially nursing and anesthesia, flat or declining reimbursement despite higher supply, drug, and labor costs and increasing regulatory and quality expectations.
This combination puts pressure on patient safety, throughput, margins, and staff morale at the same time. My solutions have included the following factors.
1. Tightening Patient Selection & Risk Stratification
- More rigorous pre-op screening and medical optimization
- Clearer exclusion criteria tied to acuity, BMI, comorbidities, and social support.
- Stronger collaboration with surgeons, anesthesia, and PCPs to avoid “creep” beyond ASC-safe cases.
2. Standardizing Care to Manage Complexity Safely
- Procedure-specific pathways and ERAS-style protocols
- Standardized anesthesia plans and discharge criteria
- Data-driven case time and recovery benchmarks to reduce variability.
3. Investing in Workforce Stability
- Cross-training staff to improve flexibility.
- Focusing on retention over recruitment (culture, schedules, leadership visibility)
- Using productivity data to right-size staffing without burnout
4. Relentless Focus on Efficiency
- Block-time optimization and surgeon performance transparency
- Supply chain standardization and vendor consolidation
- Leveraging technology for scheduling, documentation, and patient communication
5. Strategic Growth, Not Just More Volume
- Adding service lines that fit the ASC model (orthopedics, pain, GI, ophthalmology)
- Evaluating cases based on margin and risk, not just volume
- Strengthening hospital and payer partnerships to ensure alignment
The overall mindset shift has changed from “How much can we do?” to “What should we do exceptionally well?” all under the regard of patient safety. Successful ASCs today are moving from the discipline; clinical, operational and financial. This is what allows ASCs to thrive in this new and challenging environment.
OS collaborations for policy advocacy, and increased use of ASCs to optimize throughput and financials.
Andrew Lovewell. CEO at Columbia (Mo.) Orthopaedic Group: The most friction we are experiencing right now is around payer behavior and reimbursement contracts. The constant pressure for practices to jump through hoops for approval/authorization is daunting and leaves patients in the dark. Additionally, the continued attempts by payers to unilaterally reduce physician and facility reimbursement or deny claims based on payer policy are so egregious today. Every practice and ASC today is strengthening its documentation processes to eliminate any potential audit issues. Unfortunately, the shifting tides from the payers make it impossible to keep up with the irrational behavior. Not only are we fighting harder to keep the money that we are already contractually obligated to receive, the payers are also refusing to even communicate regarding compensating providers and ASCs at a fair market rate for these efforts.
Ken Rich, MD. President of Raleigh Neurosurgical Clinic: I think in a practice with multiple doctors who each have their mid-level and scheduler you have to avoid the “seven brides for seven brothers” syndrome. Those teams can become very competitive to the detriment of the practice and the outcomes of the patient. To combat this, we have our doctors in mid levels in one big room doing clinic, which quite often leads to a cooperative approach to a patient’s problem. We also try to do several social events every year like take everyone to a hockey game or have a pig pick. These social interactions tend to develop friendships among the teams.
These leaders are speaking at Becker’s 23rd Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference, set for June 11-13, 2026, at the Swissotel Chicago.
