Many spine and orthopedic leaders say the greatest source of friction in their practices comes from administrative resistance. From prior authorizations to reimbursement cuts and mounting operational costs, experts discuss where these hurdles hit them the hardest.
Question: Where are you seeing the most friction in your practice? How are you approaching it?
Joseph Bosco, III, MD. NYU Langone (New York City): The desire to be innovative and deliver the finest, cutting-edge patient care motivates orthopedic surgeons. However, in today’s healthcare ecosystem we need to understand the value proposition of our care. All new treatments increase cost. The question is if the added costs are justified by improved outcomes. We need to be responsible stewards of medical economics while striving to provide the most innovative care. In the past, new technologies were incorporated without a concern for cost. We can no longer afford to do that. The conflict between innovation and value is the biggest area of friction in medicine and especially orthopedic surgery.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: The idea of friction to me is something that inhibits you from doing a good job or growing your business, and in medicine it’s physicians getting paid. The latest area of friction is insurance companies creating problems with essentially what has been laid out as the rules of the road, and they continue to try to employ tactics to claw back or otherwise underpay physicians. The latest instance was when I had to do a surgery on a patient that involved a vascular surgeon getting into the abdomen to place an artificial disc. In order to do that safely, you have to employ the services of an approach surgeon. But the insurance decided to send a letter and say I didn’t need the approach surgeon. What we’ve seen now is new levels of dishonesty and clawbacks from the insurers, and there’s a lot of problems right now with physicians getting paid. It’s going to lead to more and more issues with physicians staying independent and staying in-network.
The other thing that we found in terms of friction is the websites of the insurers remain Byzantine, and it’s becoming very hard to navigate. Let’s say a physician wants to drop an insurer. You have to send two or three emails to find out the right website address of where you can go and modify your contracts and then drop it. Even when you do that, there is no confirmation or receipt. So you could potentially go on for months thinking you’re out of network, and actually still be in network, which can lead to problems with patients, billing issues, potential allegations of fraud and all sorts of things that make you out to be the bad guy even when you’ve done the due diligence. You can have an order confirmation from the minute you buy something on Amazon. To not be able to have a confirmation from insurers I think is intentional.
Gregory Byrd, MD. Olympia (Wash.) Orthopaedic Associates: Wage inflation and state-mandated intermittent paid family and medical leave have made staffing increasingly difficult and costly. In response, we have begun exploring alternative models that are less dependent on human resources, leveraging technology to maintain efficiency and operational flow. These solutions have enabled fewer staff members to perform the same, if not greater volume of work, while minimizing disruptions to both the patient and provider experience caused by unexpected absences.
At the same time, we are seeing growing barriers from payers that make it more challenging for patients to access needed care. These barriers include expanded pre-authorization requirements, increased denials, and delays in the authorization process. As a result, additional staff time and effort are required to secure care as intended by providers, often involving repeated back-and-forth with payers or more extensive screening prior to scheduling. Here again, technology has played a critical role by reviewing clinical notes and insurance information upfront, allowing for more timely authorizations and reducing administrative friction for both patients and staff.
Tan Chen, MD. Inova Health System (Fairfax, Va.): Administrative hurdles like prior authorizations can delay care and create frustration for patients who are already in significant pain. I try to buffer that as much as possible by using clear, evidence-based criteria and streamlined workflows so approvals happen faster and patients aren’t caught in the middle.
The other major issue is setting expectations. Many patients come in hoping for a quick or complete fix, and spine care is rarely that simple. I focus on early and honest conversation, what surgery can and can’t help with and what recovery really looks like, so that patients feel informed and supported rather than surprised.
By reducing delays and aligning expectations up front, we can lower stress for patients and improve both their experience and outcomes.
Brian Curtin, MD. OrthoCarolina Hip and Knee Center (Charlotte, N.C.): We as a practice continue to see friction in regards to prior authorization from payers that delays surgeries and consumes both physician time and practice resources. Back and forth between the payer and office utilization staff with demands for further documentation or clarification can take days or weeks sometimes to get finalized with the patient often in limbo for scheduling. Peer to peer reviews scheduled for two hour windows during a busy office day are incredibly disruptive and often unnecessary upon completing the call.
Sean Gipson. CEO and Division president of ASCs at Remedy Surgery Center (Hurst, Texas): One of the most challenging times with our ASC practice today is the intersection of rising patient complexity and mounting operational pressure; all while reimbursement tightens.
The core challenge is that ASCs now see much of the following: Older, sicker patients with multiple chronic conditions, more complex procedures migrating from hospitals to outpatient settings, persistent workforce shortages, especially nursing and anesthesia, flat or declining reimbursement despite higher supply, drug, and labor costs and increasing regulatory and quality expectations.
This combination puts pressure on patient safety, throughput, margins, and staff morale at the same time. My solutions have included the following factors.
1. Tightening Patient Selection & Risk Stratification
- More rigorous pre-op screening and medical optimization
- Clearer exclusion criteria tied to acuity, BMI, comorbidities, and social support.
- Stronger collaboration with surgeons, anesthesia, and PCPs to avoid “creep” beyond ASC-safe cases.
2. Standardizing Care to Manage Complexity Safely
- Procedure-specific pathways and ERAS-style protocols
- Standardized anesthesia plans and discharge criteria
- Data-driven case time and recovery benchmarks to reduce variability.
3. Investing in Workforce Stability
- Cross-training staff to improve flexibility.
- Focusing on retention over recruitment (culture, schedules, leadership visibility)
- Using productivity data to right-size staffing without burnout
4. Relentless Focus on Efficiency
- Block-time optimization and surgeon performance transparency
- Supply chain standardization and vendor consolidation
- Leveraging technology for scheduling, documentation, and patient communication
5. Strategic Growth, Not Just More Volume
- Adding service lines that fit the ASC model (orthopedics, pain, GI, ophthalmology)
- Evaluating cases based on margin and risk, not just volume
- Strengthening hospital and payer partnerships to ensure alignment
The overall mindset shift has changed from “How much can we do?” to “What should we do exceptionally well?” all under the regard of patient safety. Successful ASCs today are moving from the discipline; clinical, operational and financial. This is what allows ASCs to thrive in this new and challenging environment.
Vamsi Kancherla, MD. Specialty Orthopaedics (Gainesville, Ga.): We’re facing significant hurdles with insurance approvals and shrinking reimbursements, which postpone minimally invasive spine options including endoscopic procedures and robotic fusions for patients. This inflates operational costs and hampers efficiency given the lack of specialized personnel. Our approach includes digital platforms for streamlined processes and challenges, AAOS collaborations for policy advocacy, and increased use of ASCs to optimize throughput and financials.
Ira Kornbluth, MD. President at Clearway Pain Solutions (Annapolis, Md.): Clearway Pain is experiencing ongoing friction regarding payer prior authorization policies. Prior authorizations rules can be opaque and inconsistent, resulting in delays in care as well as frustration for providers, patients and the practice. Prior authorization causes a major bottleneck in scheduling treatments and creates tremendous administrative costs for the healthcare system.
Joseph Lamplot, MD. Endeavor Health Orthopaedic & Spine Institute (Skokie, Ill.): The greatest friction in my practice is insurance denials for imaging and surgical care, particularly during the pre-authorization process. Even with appropriate initial evaluation and conservative management, we are seeing increasing resistance from payers. Our approach has been to double down on thorough documentation, evidence-based pathways, and direct peer-to-peer engagement to advocate for our patients. Looking ahead, the real opportunity is to develop more efficient, standardized authorization frameworks in collaboration with insurers and policymakers — ones that prioritize clinical appropriateness, reduce administrative burden, and support cost-effective care without compromising quality or outcomes.
Andrew Lovewell. CEO at Columbia (Mo.) Orthopaedic Group: The most friction we are experiencing right now is around payer behavior and reimbursement contracts. The constant pressure for practices to jump through hoops for approval/authorization is daunting and leaves patients in the dark. Additionally, the continued attempts by payers to unilaterally reduce physician and facility reimbursement or deny claims based on payer policy are so egregious today. Every practice and ASC today is strengthening its documentation processes to eliminate any potential audit issues. Unfortunately, the shifting tides from the payers make it impossible to keep up with the irrational behavior. Not only are we fighting harder to keep the money that we are already contractually obligated to receive, the payers are also refusing to even communicate regarding compensating providers and ASCs at a fair market rate for these efforts.
Brian Nwannunu, MD. Texas Joine Institute (McKinney): I am seeing the most friction in my practice with issues regarding prior authorizations. I have even had to do a “peer to peer” with an insurance company on the morning of a scheduled elective surgery for a patient of mine. As one can imagine, this added stress and angst to the already daunting surgical environment that the patient has to endure. Adding a possible increased financial burden was not something I wanted the patient to have to deal with as well. Thus, I had to delay my operative day (and inconvenience other patients) in order to be available for the “peer to peer” conversation with the insurance company.
What we have done now is learn the nuances of each respective insurance company and dedicate a team from my clinic/office staff that only deals with prior authorizations. This has helped tremendously, but we still find hurdles in what seems like an ever moving goal post.
John Prunskis, MD. DxTx Pain & Spine (Chicago): The greatest challenge facing the practice is the ongoing decline in reimbursements, coupled with the growing burden of pre-approvals and pre-certifications for procedures. Meanwhile, insurance companies are reporting record profits while limiting or placing administrative barriers to patients’ access to the care they need.
Best way to approach this is to be persistent in the face of increasing administrative burden and work with one’s U.S. senators and congressman to address this issue through legislation.
David Russo, DO. Columbia Pain Management (Hood River, Ore.): The greatest friction we see is at the intersection of payment policy and site of service. Independent practices are being pushed toward higher-cost settings by administrative burden, utilization management, and misaligned incentives, even when lower-acuity care can be delivered more efficiently in office-based or ASC environments. Our approach has been to invest in operational discipline and data transparency, build ASC-aligned care pathways, and stay relentlessly focused on appropriate patient selection and outcomes. The goal is not to chase volume, but to preserve clinical autonomy and cost-effective access while navigating an increasingly centralized and rule-driven system.
Bus Tarbox, MD. Columbia (Mo.) Orthopedic Group: Looking ahead, the most significant source of friction within our group continues to be the challenges posed by insurance companies.
We continue experiencing mounting pressures from the ongoing downward trend in the Medicare conversion factor. More concerning are the unilateral reimbursement decisions made by large insurers (including major payers like the “BUCAs”), which often reduce payments without sufficient justification, negotiation, or external oversight. I see little indication that this pattern will reverse in the near term.
These trends are intensifying financial strain on independent practices. Providers are caught between declining reimbursements on one side and rising inflation, overhead costs, and operational expenses on the other. This dynamic fosters internal discontent across service lines, as those with higher proportions of Medicare patients face disproportionate impacts compared to others. If the trend persists without meaningful reform, I believe access to care for Medicare beneficiaries could become significantly more limited, potentially driving further consolidation or closures of independent practices.
Additionally, the insurance industry remains largely unchecked. While I am not advocating for heavy government intervention in our practices, the lack of accountability allows payers to implement reimbursement cuts arbitrarily. Greater transparency, fair negotiation processes, and balanced oversight are needed to protect both providers and patients.
This situation underscores the urgency for unified advocacy — whether through our professional organizations, legislative channels, or collective action — to address these systemic issues and safeguard the viability of patient access and independent practice.
Katherine Wagner, MD. Ventura (Calif.) Neurosurgery: There is even more fear and uncertainty in healthcare right now than in 2024 and 2025. Changes to health plans and premiums have made my patients nervous to seek care. Patients and families are more worried about costs than they had been before. The hospital systems where I practice are also worried about their financial health. As a result, many hospitals are more focused on reigning in costs than on expanding services. Many facilities have hiring freezes in place because of serious revenue cycle challenges and changes in state and federal funding.
Eric Wieser, MD. AOA Orthopedic Specialists (Arlington, Texas): Clearly, the biggest point of friction in my orthopedic spine practice is in insurance denial and scheduling. There is a significant bottleneck in the ability to getting a patient scheduled and actually into the operating room after seeing them in the clinic with surgical indications and appropriate work up. The insurance companies, especially Medicare Advantage plans, have created their own clinical indications and preoperative requirements that are different for each carrier. They require unrealistic preoperative checklists that often cause undue delay and even additional pain for our patients. This has created major scheduling issues and ultimately canceled cases, which wastes significant time and clinical efficiency.
We are approaching this at our group by scheduling these patients further out and adhering to an updated checklist of requirements from the carriers to ensure approval at the time of scheduled surgery. Updating this checklist regularly has improved my clinical efficiency, and I have experienced far fewer last-minute cancellations. There are artificial intelligence options that can be utilized to streamline these tasks at relatively low cost. This is an opportunity to employ technology into your practice to increase your efficiency.
Christopher Yeung, MD. Desert Institute for Spine Care (Phoenix): One of the greatest areas of friction in our practice today is the administrative burden surrounding surgical case authorization and post-operative reimbursement. Nearly every surgical case now requires prior authorization. Approximately 30% of cases are initially denied, which then require second-level appeals or peer-to-peer reviews before we can proceed. This significantly increases the amount of staff time required before a patient ever reaches the operating room. The friction continues after surgery. Depending on the payor, 10% to 15% of charges are denied post-operatively, requiring formal appeals and reprocessing. While we maintain a strong denial recovery rate, the time, labor, and operational cost associated with these denials is substantial including:
- We have invested in highly trained authorization and revenue cycle staff dedicated to complex surgical cases.
- We track denial trends by payor and procedure to proactively strengthen documentation and submission quality.
- We standardize clinical and operative documentation to better support medical necessity upfront.
- We prioritize rapid peer-to-peer meetings
Even with these efforts, this remains one of the most resource-intensive parts of running a surgical practice today. The friction is not clinical — it is administrative — and it continues to grow each year.
The leaders featured in this article are speaking at Becker’s 23rd Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference, set for June 11-13, 2026, at the Swissotel Chicago. If you would like to join the event as a speaker, please contact Carly Behm at cbehm@beckershealthcare.com.
