Payers have historically treated spine surgery as a default hospital procedure, but that assumption is increasingly at odds with clinical reality. Advances in minimally invasive techniques, enhanced recovery protocols, and rigorous patient selection have made outpatient spine surgery a safe, cost-effective standard of care.
Yet outdated coverage policies, administrative barriers and reimbursement structures that don’t reflect total episode value continue to stand in the way of broader adoption.
Twelve spine and ASC leaders joined Becker’s to discuss what payers get wrong about outpatient spine surgery.
The 12 leaders featured in this article are speaking at Becker’s 23rd Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference, June 11-13, 2026, at the Swissotel Chicago.
If you would like to join the event as a speaker, please contact Patsy Newitt at pnewitt@beckershealthcare.com.
Question: What do payers most misunderstand about outpatient spine surgery — and what would change if they got it right?
Ray Brown. CEO Lake Lucien Surgery Center (Maitland, Fla.): That we are their partners in reducing healthcare costs, and that we should be actively working together to migrate more cases to ASCs
Bruce Feldman, Administrator of Eastern Orange Ambulatory Surgery Center (New York City): I think that the thing payers most misunderstand about outpatient spine surgery is that advances in minimally invasive techniques through the use of technology has allowed many complex spine cases to now be performed in the ASC setting with fewer rates of infection, better clinical outcomes and higher patient satisfaction. It is also financially more cost effective for payers from a reimbursement perspective then performing these cases in the hospital. These are all things that payers could achieve if they got it right.
Megan Friedman, DO. Chair and Medical Director at Pacific Coast Anesthesia Consultants (Los Angeles): Payers often still apply older assumptions around risk and complexity to outpatient spine surgery. From an anesthesia perspective, advances in perioperative care, pain management and patient optimization have changed what can safely be performed in the outpatient setting. If they recognized that, we would likely see more patient-specific decision making, fewer unnecessary barriers, and better alignment between quality, access and cost.
Michael Gale. Administrative Director at Sentara Health’s Obici Ambulatory Surgery Center (Suffolk, Va.): There are significant reimbursement issues. Simply put, the implant devices themselves are considered a “pass through” expense, which means that the approximate cost is reimbursable in addition to the reimbursement for the procedure. However, if you happen to be in a Medicare Fiscal Intermediary jurisdiction that does in fact pay you for the cost of the device, Medicare will reduce the reimbursement of the procedure by as much as 85%. Conversely, if you are not being reimbursed on the cost side (pass through expense) you are, by definition, being reimbursed for the procedure alone. Being reimbursed for the procedure alone is preferable financially. Being aware of this can have a profound impact on how you manage the volume of cases from Medicare/government payors, et al, for this neuro/back surgery.
Some commercial payers also compensate you for the device expense and pay for the procedure at full commercial reimbursement rates.
Sean Gipson. CEO and ASC Division President of Remedy Surgery Center (Houston): Outpatient spine surgery is no longer an emerging concept. It is a mature, data-backed shift in how elective spine care is safely and efficiently delivered. Yet many payer policies haven’t fully caught up. Too often, coverage decisions still reflect an older assumption: that spine surgery belongs in the hospital by default, and anything else is an exception.
The reality today is more nuanced and more compelling. When you look closely at modern outpatient spine programs, the issue is not whether spine surgery can be done safely outside the hospital. The question is which patients, in which systems, with which protocols. That distinction changes everything in today’s surgical market.
The safety narrative is outdated. A common misconception is that outpatient spine surgery carries inherently higher risk than inpatient hospital care. This belief is largely rooted in older open surgical techniques and historical hospital-based data. However, today’s reality looks very different. Minimally invasive approaches have reduced physiologic stress. Standardized anesthesia protocols improve recovery. Enhanced recovery pathways reduce complications and admissions. High-volume ASC teams operate with tight workflow consistency. In well-selected patients, outcomes are consistently comparable, and in many cases superior, to hospital-based elective spine surgery.
“Hospital equals safer” is not always true. The assumption that hospitals are the safest setting for spine surgery does not always hold in elective care. Hospitals often introduce variables that ASCs are designed to eliminate. Greater case-to-case variability in teams and processes. Competing acuity demands that disrupt elective flow. Higher exposure risk in complex inpatient environments. In contrast, mature spine ASCs benefit from several things as well. Highly standardized care pathways. Dedicated surgical teams. Repetition that drives efficiency and consistency. Safety is not a function of the building. It is a function of the system. Risk models haven’t kept up with clinical reality. Many payer policies still rely on rigid exclusion criteria tied to age, ASA class or comorbidities.
While risk stratification is essential, these static thresholds can miss the bigger picture. Modern outpatient spine programs safely treat appropriately selected patients. ASA II–III patients, well-controlled chronic conditions, and common degenerative spine pathologies. The differentiator is not just patient characteristics, it is the maturity of the perioperative protocol supporting them.
The savings story is bigger than the site-of-service shift. It is easy to view ASC spine savings as simply lower facility reimbursement. But the real economic impact is structural. More efficient OR utilization, reduced implant and supply variability, lower complication rates in elective populations and decreased post-acute utilization in appropriate cases. When optimized, outpatient spine care improves the entire episode of care, not just the surgical day.
Complexity is evolving faster than policy. Perhaps the biggest gap is the definition of “appropriate complexity.” Procedures such as one- to three-level [anterior cervical discectomy and fusions], lumbar decompressions, select minimally invasive fusions are increasingly performed safely in outpatient settings at high-performing ASCs. Yet payer policy often lags behind clinical capability, defaulting to a “hospital-only” categorization for procedures that no longer require it.
So what changes when payers get it right? When payers align coverage with modern spine care delivery, the impact is significant. Better access, patients receive timely care in the right setting instead of waiting for hospital availability. Lower total cost of care. Savings extend beyond facility fees to include complications, readmissions and post-acute utilization. Smarter site-of-service policy. Approval shifts from blanket rules to capability-based networks of accredited spine ASCs. Improved system efficiency. Hospitals can focus on true high-acuity spine cases while ASCs manage appropriately selected elective volume.
The bottom line is that outpatient spine surgery is no longer an alternative model. It is a parallel standard of care for appropriately selected patients. The opportunity for payers is not to “approve more ASCs.” It is to modernize the framework entirely, moving from site-based assumptions to capability-based decisions grounded in outcomes. Those who make that shift will not only reduce cost. They will improve access, efficiency and quality across the spine care continuum.
Michael Lewis. Chair of Anesthesiology and Pain Management at Henry For Health + Michigan State University (Detroit): Outpatient spine surgery is not inpatient care moved to a cheaper setting. Modern outpatient programs depend on rigorous patient selection, minimally invasive techniques, specialized teams and standardized recovery pathways that reduce complications, shorten stays, and lower downstream utilization. Payers who evaluate these programs through an inpatient lens focus narrowly on procedural cost rather than total episode value, driving excessive prior to authorization requirements, inconsistent coverage policies and delays in appropriate care.
High-performing outpatient spine programs have already demonstrated the clinical and economic case. Reimbursement models should follow, shifting from utilization management toward outcomes-based partnerships, bundled payments, and center-of-excellence strategies. Patients gain faster recovery, lower infection risk and quicker return to function. Payers gain predictable long-term costs and measurably better outcomes. Both goals are achievable when the evaluation framework matches the care model.
Paul Lynch. Founder and CEO of US Pain Care (Scottsdale, Ariz.): What many payers misunderstand about outpatient spine surgery is that spine care today is fundamentally different from what it was even a decade ago. Advances in minimally invasive techniques, anesthesia, enhanced recovery protocols and patient selection now allow many spine procedures to be performed more safely, and at a significantly lower total cost in ASCs compared to hospitals. At the same time, many payer models still approach spine care in silos instead of focusing on total longitudinal outcomes for the patient. In many cases, evidence-based neuromodulation and restorative therapies may be more cost-effective and clinically appropriate earlier in the treatment continuum, potentially preventing unnecessary surgery while reducing opioid exposure and long-term disability. If payers fully embraced both modern outpatient spine pathways and earlier use of evidence-based neuromodulation and restorative therapies, the result could be better patient outcomes, lower complication rates and meaningful reductions in overall healthcare spending.
Sean Nguyen. System Director of Interventional Pain at Ochsner Health (New Orleans): Innovation has played a significant role in the evolution of pain medicine, from basic injections to neuromodulation, minimally invasive surgeries and, more recently, emerging biologic therapies. Over the past decade, outpatient spine surgery and interventional pain treatments have become increasingly important options for managing back pain, complementing more conservative approaches like medication management and physical therapy.
One area where there may be opportunity for alignment is in how these advancements are reflected in payer clinical and operational approaches. In some cases, existing guidelines may not fully incorporate newer, FDA-approved innovations or the latest evidence-based practices in chronic low back pain. As a result, prior authorization and peer-to-peer review processes can sometimes be challenging when there is variability in specialty expertise or familiarity with evolving treatment options.
Greater collaboration can be achieved by incorporating spine specialists into review processes and regularly updating clinical guidelines, ensuring that treatment plans are evaluated with the most current information. This alignment has the potential to reduce administrative complexity for both payers and providers while supporting more timely patient access to appropriate care and pain-relief treatments.
Melissa Rice. Administrator of Loyola Ambulatory Surgery Center (Oakbrook Terrace, Ill.): Payers often underestimate two critical realities of outpatient spine surgery: the rigor of patient selection and the true value of the ambulatory setting in driving both quality and cost efficiency.
First, there is a persistent misconception that outpatient spine procedures are simply inpatient cases shifted to a lower-cost setting without meaningful differentiation. In reality, successful outpatient spine programs are built on highly disciplined patient selection, evidence-based protocols, and carefully coordinated perioperative pathways. Surgeons and ASC teams are not taking the same risk profile into a different site of care — they are treating the right patients in the right setting, supported by standardized workflows that minimize complications and optimize recovery.
Second, payers frequently undervalue the total cost-of-care savings. While professional and facility reimbursement in the ASC setting is lower, the broader economic impact is often overlooked. Outpatient spine surgery consistently demonstrates reduced length of stay, lower infection rates, fewer readmissions, and faster return to function. When these downstream savings are accounted for, the ASC model is not just less expensive — it is more efficient and, in many cases, delivers superior outcomes.
If payers fully aligned with these realities, several meaningful changes would follow. We would see broader procedural approvals in the outpatient setting, more rational reimbursement structures that reflect clinical complexity rather than site-of-service bias and fewer administrative barriers that delay care. Most importantly, alignment would accelerate the shift toward high-value care — expanding patient access to safe, efficient and patient-preferred surgical options.
Ultimately, getting this right is not just about reimbursement policy — it’s about recognizing that outpatient spine surgery, when done appropriately, is a cornerstone of value-based care.
Ken Rich, MD. Medical Director and Chair of Raleigh (N.C.) Neurosurgical Clinic: They simply don’t get how much money they’re throwing away on inpatient spine surgery that should be done in ASCs. Internally, they put up all sorts of precertification barriers and payment barriers to pre-certified surgeries in a generic manner rather than looking at what practices do a significant amount of surgery in ASCs. Giving them priority in prior authorization and expediting appropriate payments in the long run. Would encourage these doctors and practices and save the insurers a ton of money in the long run.
Jacob Rodman. CEO of Raleigh (N.C.) Neurosurgical Clinic: Payers often misunderstand that outpatient spine surgery is not about doing less care — it is about doing the right care in the right setting for the right patient. When appropriate patients are treated in an ASC or outpatient environment, they can receive high-quality, efficient, lower-cost care with excellent outcomes and a better patient experience. If payers got that right, prior authorization and site-of-service decisions would become more clinically aligned, less adversarial and more focused on value. We could reduce unnecessary delays, lower overall cost of care and allow surgeons and care teams to spend more time taking care of patients instead of fighting administrative barriers. Currently, in my opinion, the payors are not putting patients first by continuously pushing back against ASCs and ambulatory spine care.
Tian Xia, MD. Director and Pain Management Specialist at American Health Care Centers and CEO of Integrated Pain Management (Chicago): No. 1: Outpatient spine surgery involves implant in most circumstances, so if payor wants to save money and not pay for implants separately, ASC can’t perform these services.
No. 2: ASCs are obviously a lot cheaper than hospitals, and carry much less risks of nosocomial infections and iatrogenic complications, which would contribute to even less costs. However, I don’t think insurance companies understand that.
At the Becker's 23rd Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference, taking place June 11-13 in Chicago, spine surgeons, orthopedic leaders and ASC executives will come together to explore minimally invasive techniques, ASC growth strategies and innovations shaping the future of outpatient spine care. Apply for complimentary registration now.
