Billing and payment are among the most complex aspects of day-to-day administrative work for ASC leaders — and it’s rarely due to the ASC itself.
Ellen Rostron, business operations manager at Boston Out-Patient Surgical Suites, told Becker’s that a common problem she faces is patients calling to ask why they still haven’t received a bill for a surgery performed months earlier. The answer, she said, is usually the same: the claim is still tied up in appeals.
“That’s embarrassing,” she said. “We didn’t do anything wrong, but you get a denial, and then you have to send in a first-level appeal, then you have to send in a second-level appeal.”
Ms. Rostron oversees business operations at the ortho-heavy ASC, which runs eight operating rooms and credentials physicians across orthopedics, general surgery and spine. Her department manages work comp negotiations and authorizations, coordinating with the clinical team to make sure cases are both medically and financially appropriate before they’re scheduled. Lately, that work has increasingly meant tracking how commercial payers treat codes differently than Medicare does — and bracing for the moment a case that was authorized gets denied anyway.
Ms. Rostron is not alone in her frustration with prior authorization denials. According to one American Medical Association survey, 31% of physicians said prior authorizations are often or always denied, with another 75% saying that denials have increased either somewhat or significantly over the last five years.
The strain may be increasing more at ASCs as cases shift to the outpatient setting. According to HST Pathways’ latest “State of the Industry” report, 46% of ASCs completed prior authorizations in 2024, up from 42% in 2023.
The gap between denials and authorizations shows up most clearly around new technology codes, Ms. Rostron said. Medicare will add a reimbursement pathway for a device or procedure, but commercial payers don’t have to follow suit — and often don’t.
She pointed to a specialty hand implant with a technology code that Medicare currently reimburses, but that at least one commercial payer does not.
“Codes will get added through Medicare, which is great, but it does not always translate into the commercial payers,” she said.
The workaround, for now, is internal education. Ms. Rostron’s team has built out worksheets by specialty that spell out which payers cover which codes and under what circumstances, so physicians know before they operate whether a case can safely come to the ASC.
Even that only goes so far, because payers can still deny a claim after the fact by reclassifying the procedure — labeling an implant or graft as investigational or experimental even when a contract otherwise allows for it, she said.
“They all have their buzz phrases, and it makes it hard to know, across the board, that we can always do an ACL with an allograft, because you’re likely going to eat the allograft due to a payer decision,” she said.
That inconsistency is compounded by how differently each payer handles authorizations in the first place. Some allow a 24- to 48-hour window to amend an authorization after surgery if the procedure performed differs from what was originally requested; others don’t allow retroactive amendments at all. Getting that amendment filed depends on the physician’s scheduling office understanding the urgency — something Ms. Rostron’s team has little control over, since the request has to originate there.
She described how that plays out with a specific procedure code. Her team secures authorization for a case such as an ACL repair ahead of time, but if the surgeon performs additional related work once in the operating room, that added work isn’t automatically covered under every payer’s rules. When that happens, her team has to go back and request the additional codes — and the payer can simply decline.
By contrast, she said, Medicare’s process is close to frictionless.
“Medicare has figured this out, and they do a really good job of reviewing, paying — it’s hardly ever wrong,” she said. “They pay according to the fee schedule, and then they assign their 20%, it crosses over. It’s so streamlined. You know it can be done.”
Ms. Rostron said she’s skeptical that regulators fully grasp how the fragmentation plays out for patients. A denial doesn’t just create administrative work for her billing company — it leaves patients in limbo over what they owe, sometimes for months after their surgery.
“Six months later, they’re not going to be interested in paying off that deductible,” she said. “They’re going to be like, ‘Yeah, my window closed. I’ve spent all my money for the year.'”
She’d like to see payers standardize the process, rather than routing different procedures through different authorization systems even within the same payer. “I wish they would standardize the authorization,” she said.
Last year, over 60 major health insurers pledged to streamline prior authorization processes — but few physicians think these pledges have made a difference in PA burden, according to the AMA’s “2025 AMA Prior Authorization Physician Survey,” released May 13. Recently, UnitedHealthcare reaffirmed this pledge, saying it would pare down PA for 30% of applicable services.
Despite the recent promises and the “Consensus Statement on Improving the Prior Authorization Process” being released in 2018, nearly seven years before this survey, physicians report health plans have made little progress honoring their commitments. Only 16% of physicians working with UHC and 16% working with Cigna said those changes actually reduced the number of PAs they complete.
Many physicians would agree with Ms. Rostron. According to a 2024 survey by Medscape, when given options of different reforms for prior authorization procedures, 51% said that they supported uniformity among payers. Another 19% said that greater automation on the provider’s end would help, 12% supported a central database of procedures, and another 8% and 9% supported more e-filing options from payers and other options, respectively.
Until a more organized effort to streamline these processes is in place, Ms. Rostron said, closing the gap between what’s authorized and what’s actually billed will keep falling on ASC staff. “You can’t just set it and forget it in this line of business,” she said. “You have to really stay on top of it.”
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.