ASC leaders say prior authorization has become the most damaging pain point in payer relationships, delaying care even after clinical decisions are made and surgeries are scheduled.
Four ASC leaders joined Becker’s to discuss the most frustrating parts of working with payers today.
Editors’ note: Responses were edited lightly for clarity and length.
Question: What’s the most frustrating part of working with payers today — and what’s the downstream impact on patient care or access?
Elisa Auguste. Administrator of Precision Surgery Center and Vice President of New York State Association of ASCs: One of the most frustrating aspects of working with payers is the authorization process and the constant battle to be paid for services already rendered. In orthopedics, we care for patients experiencing varying levels of pain, whether from traumatic injuries or the natural breakdown of the aging body, and delays in care can directly impact outcomes.
While I understand that prior authorizations exist to protect patients and prevent unnecessary services, the reality is that the process often comes at the patient’s expense. For example, if a patient breaks their wrist, why does it sometimes take two weeks and a peer-to-peer review to obtain authorization for surgery? These peer-to-peer conversations are frequently frustrating for surgeons, especially when the reviewing physician is not of the same specialty. It’s difficult to justify the medical necessity of a distal radius or rotator cuff repair to someone who does not practice orthopedics.
Even after navigating the authorization process, providers still face the risk of denial. Payers often rely on the caveat that “authorization is not a guarantee of payment.” Surgeons base anticipated CPT codes on imaging and initial evaluations, but surgery is not an exact science. Once the procedure begins, injuries may be more severe than expected or additional issues may be discovered, requiring changes to coding. At that point, obtaining retroactive authorization can be just as rigid and exhausting as the initial approval process, often resulting in multiple appeals with no guarantee of payment. When reimbursement is ultimately denied, the surgery has essentially been performed for free. While patient safety and care will always come first, this cycle makes it increasingly difficult for providers and facilities to remain financially sustainable over time.
Oversight is necessary; providers absolutely should be accountable for minimizing unnecessary treatments. However, the system must evolve to reduce the frustration faced by clinicians who genuinely care about healing their patients. Too often, payers encourage cases to move to the ASC setting, only to later deny authorizations or label procedures as experimental or not medically necessary. It may be time for payers and providers to truly work together to create a more balanced system, one that relies on medically sound decision-making, minimizes patient harm, and ensures patients receive high-quality, timely care.
Peter Bravos, MD. Chief Medical Officer of Sutter Surgery Center Division (Sacramento, Calif.): One of the biggest challenges ASCs face today is navigating slow and inconsistent authorization processes. Routine procedures often require prior approvals that can take days or even weeks, creating unnecessary delays. These inefficiencies don’t just frustrate clinicians; they directly affect patients. Delayed care can worsen conditions, increase anxiety, and drive up costs. For patients in rural or underserved areas, these barriers may compound, limiting access and widening disparities.
Trina Cole. Administrator of St. Luke’s Surgicenter-Lee’s Summit (Mo.): In my perspective, the most frustrating part of working with payers today is the challenges with prior authorization. Physicians are required to participate in multiple peer reviews or information sharing just to address their professional decisions on how to take care of their patients. The impact on the patients is the delay, denial or complete cancellation of the procedure. So wasted time of the office and physician on the front side, and the increased possibility of a negative outcome for the patient on the backside.
Ashley Hilliard, RN. Administrator of Piedmont Outpatient Surgery Center (Winston-Salem, N.C.): The most frustrating part of working with payers today is the lack of transparency and consistency — particularly around prior authorization, medical necessity determinations and reimbursement methodology. Requirements change frequently; interpretations vary by payer and even by reviewer, and there is often no clear, timely way to resolve discrepancies. This can lead to delays in patient care, reduced access, administrative burden and financial uncertainty. These issues can have a negative impact on the patient, as well as the ASC.
