Hi everyone. This is Erica Spicer Mason with
Becker's Healthcare. Thank you so much for tuning
into the Becker's Healthcare podcast series.
So today we're going to talk about how
strategic collaborations
can strengthen ASC operations.
Joining me for this discussion today is Armando
Cardoso, the CEO of PayerHealth.
Armando, welcome to the podcast. Thank you so
much for being with us today. Thank you,
Erica. It's great to be here.
We're thrilled to have you. And before we
start talking about
ASC operations and all of the great insights
that you have, would you mind sharing just
a little bit more about yourself and your
background, your work in health care, with our
audience?
Absolutely.
And I appreciate folks taking the time to
listen in. I'm Armando Cardoso, CEO of PayerHealth,
and my journey in health care has taken
many turns. I began in finance, actually, versus
a health care investment banker with Morgan Stanley
in New York, advising health care companies and
later as a health care private equity investor
with Summit Partners in Boston investing in health
care companies.
But, really, it was my shift into health
care operations that shaped my path to pay
your health. I had the privilege of building
a Medicare Advantage health plan at Clover Health,
where I was the head of growth. And
later, I had the opportunity to lead the
national managed care analytics team at Ascension, one
of the largest health systems in the country.
And from these seats, I had the opportunity
to see the health care industry from very
different vantage points,
including both sides of the negotiating table.
They also gave me the chance to develop
a deep understanding of both fee for service
and value based contracting,
two areas that are more critical than ever
for ASCs facing today's mounting pressures.
These seats also showed me the challenges providers
face when navigating payer relationships.
I've seen firsthand how reimbursement challenges can limit
the growth and sustainability of even the most
efficient providers. So that's really what attracted me
to payer health and the opportunity to advocate
for providers.
Payer health is,
really made up of a a group of
great folks. I mean, we've got folks who
serve both sides of the aisle, if you
will, you know, payer and provider. And we
focus on strengthening payer relationships,
protecting margins, and building financial strategies that support
our client success.
And then on the personal side, I live
in Austin, Texas with my wife, our young
sons, and three dogs.
Oh, you've got a full house. Love knowing
that you have three dogs. I appreciate you
sharing with me, Taylor Armando.
Well, it's great to have you on with
us, and it sounds like you have so
much experience that you're bringing to the table,
a lot of perspective. And I can see,
you know, you're you're already touching on a
core concern that we know is pervasive in
the industry and especially at ASCs right now,
which is that concept of financial stability. So
excited to hear some more insights from you
there. But before we get even further, can
you also tell us a little bit more
about PayerHealth and, you know, what is the
company's mission as well?
I'd love to. You know, our our leadership
team crafted
what we've called the the payer health manifesto,
and we share with our employees. And it
it actually opens,
with us establishing our belief that providers are
the beating heart of the health care industry.
They are the ones placing their hands on
patients. They are the catalyst for change, innovation,
and improved outcomes.
So payer health exists to be a champion
for providers.
You know, our our mission is clear. We
we focus on the protecting and improving providers'
margins so they can focus on their mission,
delivering exceptional patient care.
We wanna get providers back to why they
chose to essentially
work in the field in the first place,
caring for people. And that's without the being
weighed down by the administrative burdens or constant
fights to get paid for what they've earned.
We do this through end to end payer
relationship management.
That means we fully run everything from contract
negotiations to credentialing
to medical billing and ongoing revenue cycle performance.
What we found is that many ASCs are
doing incredible work with limited teams and stretched
resources.
They're lean by design, but that also means
they're often outmatched when it comes to managing
complex payer relationships.
Payers have entire departments,
legal, actuarial,
contracting, analytics,
all designed to minimize reimbursement
and protect the payer's margins.
Most ASCs simply don't have the internal infrastructure
to keep up with that level of sophistication.
And, honestly, that imbalance is felt
most in the, I'd say, day to day
stuff. So outdated contracts, credentialing delays, denied claims,
and revenue cycle inefficiencies that chip away at
margins.
What's fascinating is if you if you really
just take a massive step back, ASCs are
one of the few bright spots that are
lowering the total cost of care in a
fee for service model. And, yes, there's been
strong growth in the number of ASCs,
but growth alone doesn't guarantee sustainability.
The reality is we've seen ASC closures, and
financial pressure is a major contributor. Becker's actually
has some great articles and insights that have
been published from industry leaders on this very
topic.
Margins are tighter. The complexity of managing payer
relationships is just growing, especially when ASCs are
expected to go head to head with organizations
that are structurally built to resist rate increases
and slow reimbursement.
The bottom line, at least as we see
it at the payer health, is that what
worked five years ago no longer works today.
Trying to optimize revenue without expert support isn't
just inefficient.
It's honestly just risky.
ASCs need to partner
with folks who understand the payer landscape
and know how to navigate it strategically. That's
what we do at PayerHealth.
And all that said, I do wanna be
clear.
You know, it's easy to vilify payers, and
and we shouldn't. There's some amazing people doing
work that's incredibly important within these organizations.
And, in fact, many of our members of
our own team came directly from the payer
side. But this is the reality of our
health care system in The United States today.
It's complex. It's uneven, and it often puts
providers at a disadvantage
unless they plan accordingly.
Our role at PearHealth is to help providers
navigate that reality and thrive despite it.
Yeah. Armando,
I really appreciate everything that you've outlined. It's
great to learn more about what PearHealth is
all about. And some of these things that
you've said are really standing out to me.
The fact that some of these financial or
sustainability strategies that worked five years ago aren't
working today. You know, growth in the ASC
space doesn't always mean sustainability.
Really, really interesting, and it really just speaks
to how quickly things are changing in the
industry.
And I also wanted to touch on too.
You said how ASCs
tend to lack that infrastructure that they need
to really get around some of these challenges.
So can you elaborate a little bit more
on what makes PearHealth especially impactful for an
ASC?
Definitely. Great question. Well, unlike large health systems,
most independent ASCs don't have entire departments dedicated
to contracting, credentialing, or revenue cycle strategy. And
even when portions of those functions do exist,
they're often siloed, and that's where pay health
fits to support. And importantly, we support with
a deep understanding that ASCs have unique considerations.
For example, ASC contracting isn't
hospital or physician contracting,
and I'm air quoting over here with a
few tweaks.
It's a completely different game. And that means
it takes a completely different approach to win.
A good example to share that's relatively recent
is how our team helped the client, in
this case, a physician group opening a a
new ASC with their contracting strategy.
The team approached the negotiation holistically.
So, you know, we considered both the professional
and facility dynamics to secure substantial increases in
the physician fees and lock in favorable ASC
rates. The team used price transparency data to
show payers what they were already paying the
local hospital for the same cases
and made it clear that the higher rates
we were proposing would still save them money.
And, you know, as anticipated,
a few payers still push back. And in
this case, we pointed out what it would
look like if we decided to go out
of network, reminding the payers of the fact
and the impact that this would have on
their members,
our clients' patients. You know? Essentially,
this would lead to the provider having to
tell patients something like,
I'm so sorry, patient. If you had this
other payer, you could get into the lower
cost ASC right away.
But
because you have payer x,
we're gonna have to send you back to
the hospital.
Oh, and and by the way, we're gonna
have to push back that date. Oh, and
and, yeah, unfortunately, it's gonna be at a
higher cost.
You know, those those types of conversations
just change the dynamics, and every payer came
to the table. And in some cases, we've
even been able to help,
clients earlier in the process while providers are
still in the planning phase to build an
ASC. We frame negotiations in those cases more
as, you know, in terms of viability.
So we'll essentially approach payers by saying, if
these rates don't make sense, this ASC is
simply not gonna get built, and you'll keep
paying higher hospital rates. That messaging
usually resonates and and works well.
So, you know,
it is important to also point out, though,
that contracting is only one piece of the
value we bring. What truly sets PayorHealth apart
is how credentialing, contracting, and revenue cycle management
work together, not in silos, but as an
integrated platform.
When we're managing all three functions, your entire
reimbursement workflow lives in one place, and our
teams have full visibility across each component.
That integration matters
because these areas constantly overlap.
For example, when a new contract or provider
goes live, our RCM team has real time
access to credentialing approvals. That means we can
submit claims immediately,
avoiding denials, rework, or delays in payment.
And if a contract is retroactive, which happens
often, our teams work together to ensure every
impacted claim is reprocessed at the correct rate,
because in most cases, payers do not do
that automatically.
We're built to catch those opportunities.
That kind of coordination,
that level of, I'll call, operational rigor is
what drives real margin impact. It really comes
down to the reality that a great contract
without operations to enforce it isn't worth the
paper it's printed on.
And the inverse,
great operations
without a fair contract, well, that's that's, I'd
say the equivalent of holding a candle to
the sun. We focus on being a true
extension for our clients and their teams, focusing
on making every dollar count.
Yeah. Thanks so much, Armando. It's helpful to
know all of this, and it it does
sound like very holistic support, you know, between
the contracting, credentialing, the RCM work, and then
all of the coordination that's going on behind
the scenes.
Really interesting.
You know, do you find that there are
any misconceptions
about these services, you know, whether it's these
services that you do as payor health or
similar companies? And what would what would you
like to clear up for anyone listening?
Definitely. I appreciate that. Well, I'd say the
most common misconception here is that we're just
a contracting service, just a credentialing team, or
just a billing company. We do offer those
services for sure, and we definitely offer them
modularly. So we can tailor solutions to our
clients' needs. But what sets us apart is
that we've built expertise across the full reimbursement
life cycle. And that means that we can
plug in exactly where we're needed while still
keeping an eye on the broader system. That
makes us a more
agile, more strategic partner.
Even in those more focused or limited engagements,
we end up being a better partner.
You know, our clients are often also surprised
by how much money is left on the
table and sometimes how quickly that changes once
we're involved.
A good example of this, I'd say, is,
that's also relatively recent is we're onboarding a
new client and found a lesser of issue.
So, you know, in this case, they were
being paid below their contracted rate because their
charge master was set too low. We helped
them correct it, and without even contacting a
payer, they saw a half a million dollar
improvement in revenue.
That kind of catch doesn't happen when functions
are operating in silos, and that's critical because
payer reimbursement structures
are complex and inconsistent,
and they use everything from
APCs,
APGs, and EAPGs
to carve outs, case rates, and multi procedure
logic.
And what's even more crazy is that payers
can change these unilaterally
without notifying the provider.
So unless you're looking across contract data, charge
data, and claims data together, you're almost guaranteed
to miss revenue opportunities
or let underpayments go uncorrected for months or
even years. That's why our integrated model matters.
Yeah. Thanks, Armando.
And, you know, looking ahead, what are some
of the things PayerHealth is focusing on or
anticipating in the next three to five years,
especially as as we've talked touched on earlier,
the health care and reimbursement model continues to
involve. Would love to know what's ahead for
you.
For sure. And and some of these are
are familiar themes, but it's so critical. You
know, first, I'd say the long running drumbeat
around value based care. It's been part of
the industry conversation for years,
but we see it as a key force.
ASCs need to be ready for more bundled
payments, outcomes based contracts, and alternative payment models.
We're helping clients get ahead of that, not
because it's suddenly everywhere, but because it's a
shift that's likely to keep building, and we
want our clients to be ready.
Second is consolidation and growth in the ASC
market.
More centers are expanding their service lines, adding
locations, or joining platforms, and that kind of
growth only works if it's backed by smart,
scalable payer strategies.
You can't expand clinical capacity without ensuring contracts
and revenue cycle operations or keeping pace. That's
a big focus area for us. How do
we help our clients scale without losing leverage
or visibility?
But one of the kind of items taking
center stage now, I'd say, and the biggest
disruptor is AI. AI is rapidly changing the
ways that payers review, flag, and deny claims.
We're seeing AI used to run clinical reviews,
identifying documentation gaps or patterns that trigger denial
recommendations.
And while payers often say that a physician
still signs off, in practice, those physicians have
often become rubber stamps for the algorithm.
That's why our RCM team matters. We're not
just working denials. We're identifying patterns across payers,
spotting inconsistencies,
and challenging decisions with real insight.
Importantly,
we're also bringing AI into our processes,
not to replace people, but honestly to make
them more effective
because the days of relying solely on headcount
to review denials, code claims, or chase status
updates are well behind us. From the bots
that automate claim status checks to AI assisted
coding and charge entry tools, we're investing heavily
in technology that streamlines the repetitive work so
our team can focus on the claims that
really require strategy, nuance, and escalation.
There is no doubt, at least in my
mind, that payers will continue using AI to
reduce reimbursement.
So our job as Fair Health is to
ensure providers have a partner who can match
that pace
and fight smart with the right data, the
right tools, and the right people.
Yeah. Sounds like a really smart approach, Armando.
So thank you so much for giving us
your take on on what's ahead and how
Pear Health is is going to support organizations
in that landscape.
So, also, before I let you go, I
also did wanna learn more about I understand
there's a partnership that you have with J
and J MedTech. So would love to just
share a little bit more about that with
our listeners and why you're excited about working
with J and J.
Definitely. Definitely.
This strategic alliance with Johnson and Johnson MedTech
is exciting because it's it's rooted in a
clear shared commitment to helping ASC succeed,
not just clinically, but economically and operationally as
well.
J and J MedTech has built what what
I consider to be a very powerful framework
focused on clinical excellence, economic value, and operational
support. And Pear Health is very proud to
be part of the resources that they bring
to the table.
While J and J delivers the world class
tools, the technology, and education to elevate care,
we help ensure that the ASC's reimbursement strategy,
payer relationships, and revenue cycle performance are just
as strong as what's happening in the OR.
And when reimbursement is aligned and systems are
efficient,
ASCs gain the headspace to focus on what
matters most, delivering excellent care.
That's how this work ultimately altogether
comes to the end output that's very important,
and that's supporting clinical excellence
too. So that's what makes this alliance so
powerful. By working together, we can bring ASCs
a more complete support system
from the operating room to the negotiating table.
It's all about helping them do more with
less
and get paid fairly for the value that
they bring to the health care system.
Sounds like a a very aligned partnership. So,
Armando, thank you so much for sharing a
bit a bit more about that. And before
we wrap up our time together, is there
anything else that maybe we didn't touch on,
that we missed, that you wanted to add
as final thoughts for our listeners?
No. Erica, I think you you really appreciated
you taking the time, and, I think this
is a great conversation.
I would say just this. PearHealth, we're a
team of experts who genuinely care.
We're not here to offer cookie cutter solutions.
We want to listen, assess, and build strategies
that are tailored to each ASC's unique situation.
So if you're interested in learning more about
how PayerHealth can support your team, you can
reach out directly through your local J and
J MedTech ASC representative
by clicking the link below the podcast.
And you could also visit us at payerhealth.com.
That's payrhealth.com
to explore more about what we do. Really
appreciated the opportunity to be here today and
enjoyed the conversation.
Likewise, Armando. Thank you so much for making
time for Becker's.
And, of course, we also wanna thank our
podcast sponsor for today, Johnson and Johnson MedTech.
Listeners, be sure to tune into more podcasts
from Becker's Healthcare by visiting our podcast page
at beckers hospital review dot com.