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.