Ask Rose

Which payers pay my ASC below market?

The short answer

The payers paying your ASC below market are the ones whose rates for your top procedures sit under the market rate for the same work. Ask Rose in plain language and she ranks every payer from most underpaid to fair, so you see which contracts lag before you renegotiate.

How Rose answers it

Ranked, not guessed

Rose sorts your payers from furthest behind market to on par, per procedure, so you know which contract to open first instead of relying on a gut feel.

A chart, then a call

Ask in plain words and Rose returns a clear benchmark chart of where each payer ranks, ending in a recommendation on which contracts are worth reopening now.

Ready for the table

Rose flags the specific procedures where a payer trails the market, giving you the concrete gaps to bring into your next renegotiation.

Below-market means below your own best rate, not a national average

The most useful benchmark for a payer's rate is not some national number, it is what other contracts pay you and your peers for the same code. A payer pays you below market when a comparable ASC, or another line on your own fee schedule, clears meaningfully higher for identical CPT work. Start there. National averages hide geography, specialty mix, and site-of-service. Ask Rose to line up each payer's allowed amount against the DataLily Insights analysis benchmark for your CPT set, then read the gap code by code. A payer can look fine in aggregate and still underpay your three highest-volume procedures, which is where the money actually leaks.

Rank the leak by dollars, not by percent gap

Sort your underpayment by annualized dollars, not the biggest percentage gap. A payer that trails benchmark by a small margin on a high-volume procedure can outweigh one that trails badly on a case you do twice a year. Multiply the per-case gap by your real volume, then you know where to spend negotiating capital. Percentages seduce operators into chasing rare cases. Ask Rose to weight each payer's rate gap by your procedure volume and return the ranked dollar exposure. Bring that list to your next renewal. A payer that costs you the most across your busiest CPTs is your first conversation, every time.

Compare code by code, because blended rates lie

Never judge a payer on a blended average. Blends bury the codes where you lose. A payer can pay competitively on your low-acuity, high-frequency procedures and quietly trail on the complex cases that carry your margin. The mix that produces a flattering average is exactly the mix that hides the leak. Pull the comparison at the CPT level, per payer, and read each line. Ask Rose to break out below-market codes payer by payer so you see the specific procedures dragging a contract down. That granularity is what turns a vague sense that a payer underpays into a defensible, line-item negotiating position.

Factor in site-of-service and case mix before you cry foul

Before you flag a payer, confirm you are comparing like for like. ASC rates should be measured against other ASC rates, not hospital outpatient benchmarks, which typically run higher for the same code. Multiple procedures on one case, implant carve-outs, and modifier rules all shift the allowed amount. A rate that looks low may be a bundling or site-of-service artifact, not underpayment. Ask Rose to hold site-of-service and procedure grouping constant when it benchmarks a payer, so the gap you see is real. Walking into a payer meeting with an apples-to-oranges comparison hands them an easy rebuttal and burns your credibility for the codes that genuinely underpay.

Time the fix to your contract's renewal and notice window

Knowing a payer pays below market only helps if you can act on it, and that depends on your contract calendar. Evergreen agreements roll automatically unless you send notice, and the renegotiation or termination notice window commonly runs 90 to 180 days per industry norms. Miss it and you are locked in for another cycle. Map every payer's renewal date and notice deadline now, then line your ranked underpayment list against it. Ask Rose which below-market payers have a window opening in the next couple of quarters. Rate intelligence is only leverage when you raise it before the clock resets, not after another year has quietly renewed.

Turn the gap into a specific, evidence-backed ask

Do not walk in asking for a general increase. Bring the payer the exact codes where they trail benchmark, your volume on each, and the market rate you can defend. Payers move faster against specific, sourced comparisons than against a blanket demand. Frame it as parity on named procedures, not a raise, and lead with the codes that matter most to both sides. Ask Rose to draft the underpaid-code list with benchmark context so your ask is precise before you sit down. The operators who win rate conversations show up with a short, dollar-weighted list and a number for each line, not a grievance.

FAQ

Frequently asked questions

How do I know if a payer is really paying below market?

Compare the payer's allowed amount to what comparable ASCs earn for the same CPT code, holding site-of-service and case mix constant. A payer is below market when identical ASC work clears meaningfully higher elsewhere or on your own other contracts. Ask Rose to benchmark each payer code by code against the DataLily Insights analysis, so you judge the gap on real procedures rather than a misleading blended average.

Should I focus on the biggest percentage gap or the biggest dollar gap?

Dollars. A small percentage gap on a high-volume procedure usually costs more than a large gap on a rare case. Multiply each per-case gap by your actual volume to get annualized exposure, then negotiate in that order. Percentages push you toward rare cases that barely move your bottom line. Ask Rose to rank below-market payers by volume-weighted dollar exposure.

Why does a payer look fine overall but still underpay me?

Blended averages hide it. A payer can pay competitively on frequent, low-acuity codes while trailing on the complex cases that carry your margin, and the average still looks acceptable. The leak lives at the CPT level. Always compare line by line, per payer. Ask Rose to break out the specific below-market codes so you see which procedures are dragging each contract down.

When can I actually renegotiate an underpaying contract?

Only during your contract's renegotiation or termination notice window, which commonly runs 90 to 180 days before renewal per industry norms. Evergreen contracts roll automatically if you miss it, locking you in another cycle. Map every payer's renewal date and notice deadline, then act ahead of the clock. Ask Rose which below-market payers have a window opening in the next couple of quarters.

What should I bring to a payer rate negotiation?

A short, dollar-weighted list of the specific codes where they trail market, your volume on each, and a defensible benchmark number per line. Frame it as parity on named procedures, not a general raise, and hold site-of-service constant so the comparison holds up. Ask Rose to draft the underpaid-code list with benchmark context before the meeting so your ask is precise.

Ask Rose

Ask Rose: "Rank the payers paying my ASC below market by annualized dollar exposure, broken out code by code for my highest-volume CPTs, holding site-of-service constant, and flag which of those contracts have a renewal or notice window opening in the next two quarters."

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