Image by Steve Buissinne from PixabayAmbulatory surgery centers (ASCs) are confronting an evolving landscape of reimbursement pressures, heightened prior authorization hurdles and new pushes for price transparency.
“Authorization has been a huge issue throughout 2024,” Todd Currier, CEO and administrator of Bend Surgery Center, said during a recent Ambulatory Surgery Center News webinar. “Trying to get pre-ops done for surgical cases, it just, it’s grown our backlog to cases and delayed procedures. … It delays care, which is not good for overall patient care.””
Oregon-based Bend Surgery Center is a 44,000-square-foot multi-specialty ASC with several operating rooms.
Currier noted that, rather than outright denials, payers are increasingly seeking additional clinical notes and extra information, which slows down the reimbursement process. As a result, payment delays have caused cash flow difficulties, a situation he expects will continue.
A recent KFF analysis showed that in 2023, Medicare Advantage insurers fully or partially denied 3.2 million prior authorization requests.
What’s more, higher-acuity cases are rapidly transitioning to the outpatient arena, which many ASC leaders see as a prime growth avenue. However, such expansion comes with expenses that commercial payers do not always address in their contracts.
“We want to bring new service lines, like higher-acuity cardiac and robotic general surgery cases, into the ASC,” Currier said. “But when payers don’t reimburse adequately for the added costs, it creates serious financial pressure.”
These denials will shape the outlook for ASCs nationwide. Prior authorization delays, shrinking margins and rising staffing costs have already set the tone, Danilo D’Aprile, VP of business development at Merritt Healthcare, said during the webinar.
Connecticut-based Merritt Healthcare is a management and advisory firm that specializes in ASCs.
And reimbursement snags are making the anesthesia shortage worse.
“I’ve had many conversations with anesthesiologists who feel the pinch of declining reimbursement,” D’Aprile said. “We’re even seeing scenarios where ASCs must offer subsidies to keep anesthesia coverage intact. That’s a major factor to build into any financial model.”
Beyond reimbursement, ASCs are under growing pressure to practice price transparency. Both speakers suggested that while efforts to clearly publish prices can foster trust with patients and employers, they may open the door to accusations of price gouging.
If an ASC’s rates appear too high compared to an office-based procedure, they risk drawing regulatory scrutiny or alienating potential direct-to-employer partners, Currier said.
“We need to make sure that we maintain [our cost‑efficient model],” he said. “If we end up partnering with anybody, [we need] to make sure that we stay small, stay agile – [that’s] what made us profitable and a leader in the health care industry.”
D’Aprile said he sees opportunity in these trends, recommending that ASCs explore direct contracting with employers who value cost effectiveness and convenient patient experiences.
“While prior authorization hurdles have soared, employers are recognizing the efficiencies ASCs can provide,” he said. “A robust direct-employer relationship can bypass some of the red tape.”
Both Currier and D’Aprile said that challenges with payers will require active advocacy at the state and federal levels.
“We’re in a period where legislation around site neutrality and price transparency is on everyone’s radar,” Currier said. “If we engage our elected officials and highlight how ASCs deliver high-quality, affordable care, we stand a better chance of shaping policy that benefits our sector and our patients.”
