Ask Rose
How do I know if my ASC is underpaid?
The short answer
Your ASC is underpaid when your reimbursement for a procedure sits behind the market for the same code and payer. DataLily Insights benchmarks your rates so that gap is visible per CPT, and Rose tells you which payers pay you behind, and by how much.
How Rose answers it
Rank the gap by payer
Ask Rose where your rates run behind the market, and get a charted answer that ranks each payer by how far below it pays.
Benchmark any CPT
Ask in plain language how your rate for a procedure compares to the market, and see exactly where you sit before your next renewal.
End in a recommendation
Rose closes every answer with a call: which payers to renegotiate first on your highest-volume codes, where a rate change moves the most.
Start with the gap between your rate and the going rate
Underpayment shows up first as a spread: what a payer pays your ASC for a code versus what other facilities negotiate for the same code in your market. If your allowed amount for a common procedure sits well below the local band, that is your signal. Pull your top 20 CPT codes by volume and by revenue. For each, compare your contracted rate against the range that comparable centers command. A single lagging code rarely moves the needle. A cluster of your highest-volume codes sitting at the bottom of the band is real money leaking every month. Ask Rose to line up your rates against market for the codes that actually drive your case mix.
Underpaid is not the same as underperforming
Draw a hard line between contract-rate problems and revenue-cycle problems. Underpaid means your negotiated rate itself is low. Underperforming means a fair rate is on paper but you are not collecting it: denials, downcoding, missed implants, timely-filing losses, or bundling you never appealed. Both cost you, but the fixes are opposite. A rate problem gets solved at the negotiating table. A collection problem gets solved in your billing workflow. Check your net collection rate and your clean-claim rate before you blame the contract. If you are collecting most of what you are owed but the owed number is small, the rate is the problem. Ask Rose to separate the two.
Benchmark by payer, code, and site of service
One blended number hides everything. Break your rates down three ways: by payer, by CPT, and by site of service. Commercial payers vary widely against each other, and the same payer often pays a different rate at an ASC than at a hospital outpatient department for identical work. Industry commentary frequently notes ASC facility rates running a meaningful discount to HOPD for the same procedure, which cuts both ways in negotiations. Rank your payers by volume, then look for the ones paying least for the codes you do most. That intersection is where a rate correction returns the most. Ask Rose to build a payer-by-code matrix so the outliers surface on their own.
Watch the contract mechanics, not just the numbers
The rate on page one is only half the story. Read how the contract escalates, renews, and terminates. Many commercial agreements auto-renew at a flat rate with no inflation adjustment, so a fair number three years ago is a losing number today. Auto-renewal notice windows commonly run somewhere in the 90 to 180 day range, and missing that window locks you in for another term. Also check whether you are paid off a fee schedule, a percent of charges, or a case rate, because each behaves differently as your costs rise. A contract that never steps up is quietly underpaying you a little more every year. Ask Rose when each of your agreements renews.
Factor in your true cost per case
A rate is only underpaid relative to what a case actually costs you to deliver. Build cost per case for your high-volume procedures: staff time, supplies, implants, drugs, and facility overhead. If a payer's allowed amount barely clears or falls under your loaded cost, that code is not just underpaid, it is unprofitable to keep doing under that contract. Implant-heavy and device-heavy cases are where thin rates turn negative fastest, especially if the contract bundles the device instead of carving it out. Know which codes you lose money on before your next negotiation so you can walk in with the exact cases and the exact dollars. Ask Rose to flag codes where your rate runs close to typical cost.
Build the case before you go to the table
Underpayment is only actionable once you can prove it in a payer's own language. Assemble three things: the codes where you lag the market, the volume behind each so the payer sees the dollars, and a clean comparison to what similar centers get. Payers respond to specifics and to leverage, not to a general complaint that rates feel low. Bring the outlier codes, your case counts, and your quality and access story. Lead with the handful of codes that carry the most volume, since those move the total faster than a long tail of small ones. Ask Rose to assemble the negotiation packet so you walk in with the codes, the counts, and the market band already lined up.
FAQ
Frequently asked questions
What is the fastest way to tell if my ASC is underpaid?
Is low collection the same as being underpaid?
How often should I benchmark my ASC rates?
Why do ASC rates differ from hospital outpatient rates?
Ask Rose
Ask Rose: "Compare my ASC's contracted rates against the market band for my 20 highest-volume CPT codes, break it down by payer, flag the codes where my rate runs closest to typical cost per case, and tell me which contracts are up for renewal in the next six months."
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