Tri-State Ambulatory Surgical Center Portfolio, 11-12 Centers in NJ/NY

$220.0M

Revenue

$55.0M

SDE

8.0x

Multiple

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Full Editorial Writeup

This is a portfolio of 11 to 12 ambulatory surgical centers operating across New Jersey and New York, each ranging from 9,000 to 25,000 square feet in prime locations. The centers deliver a broad outpatient surgical mix including orthopedics, spine, pain management, GI, ophthalmology, vascular, urology, ENT, gynecology, general surgery, podiatry and plastic surgery. The seller reports the combined NY and NJ locations generate between $100M and $130M annually each, for roughly $220M in total revenue and $55M in net cash flow, staffed by 315 employees plus a dedicated bench of specialized surgeons.

Ambulatory surgical centers are among the most durable assets in healthcare. They capture procedures migrating out of hospitals into lower-cost outpatient settings, a secular tailwind driven by payers and CMS. The listing emphasizes the centers accept both in-network and out-of-network insurance, which is a critical detail: out-of-network billing can produce outsized reimbursement but is also the single largest source of revenue volatility and regulatory risk in this asset class.

At $440M asking on a stated 8x cash flow multiple, this is a private-equity or strategic-buyer transaction, not a main street deal despite the broker's framing. The founder is retiring after roughly two decades, management is described as already in place, and the deal is offered exclusively to healthcare operators, PE, and VC. Buyers should treat the seller-reported figures as unverified until audited financials, payer mix, and physician arrangements are examined in depth.

Why we like it

Earnings quality is anchored in essential, non-deferrable surgical care that continues through downturns, with a reported $55M in net cash flow on $220M revenue for a healthy 25 percent margin. Surgical volume for orthopedics, spine, GI and vascular does not evaporate in a recession, and outpatient reimbursement rails are diversified across many payers and specialties.
The moat is structural: ambulatory surgical centers require state licensure, certificate-of-need in some jurisdictions, accreditation, and dense referring-physician relationships that take years to build. Eleven to twelve established facilities with entrenched surgeon rosters and payer contracts are extremely difficult and expensive to replicate from scratch.
Market tailwinds are strongly in favor of ASCs, as payers and CMS actively push procedures out of hospitals into lower-cost outpatient settings. This shift has driven ASC consolidation and premium valuations from strategics like Tenet's USPI, SCA, and Optum, giving a buyer a credible exit and roll-up path.
The operator advantage is scale plus an installed management team and 315 employees, meaning a buyer inherits a running platform rather than a startup. For a PE sponsor or health-system strategic, this is a bolt-on that can immediately be optimized on payer contracting, physician syndication, and same-store case volume.

How to improve it

Reconstruct the payer mix within the first 90 days to quantify how much cash flow depends on out-of-network reimbursement versus in-network contracts. Out-of-network revenue is the highest-risk line in any ASC, so rebalancing toward stable in-network contracts protects the multiple and the loan.
Syndicate ownership to high-volume referring surgeons where not already done, aligning physician economics with case volume. Surgeon equity is the single most reliable driver of sustained same-center growth in the ASC model and reduces flight risk of key producers.
Standardize supply-chain purchasing across all 11-12 sites through a group purchasing organization or consolidated vendor contracts. Implants and disposables are the largest variable cost in orthopedic and spine cases, and even a few points of savings drop straight to a $55M cash flow base.
Optimize case scheduling and block-time utilization to lift throughput in existing operating rooms without new capital. The listing itself flags growth potential; higher OR utilization is the cheapest lever and directly increases revenue per fixed-cost facility.
Build a centralized revenue-cycle management function to reduce denials, accelerate collections, and improve net collection rate across the portfolio. Multi-site ASC groups routinely leak millions to billing inefficiency, and tightening this is pure margin.
Pursue tuck-in acquisitions of nearby single-site ASCs to extend the platform and capture additional referral density. With management and infrastructure already in place, incremental centers can be onboarded at higher marginal profitability.
Evaluate service-line expansion into higher-acuity cases now permitted in outpatient settings such as total joints and complex spine. These carry premium reimbursement and align with the CMS-driven migration of procedures out of hospitals.

Diligence notes

Verify the seller-reported $220M revenue and $55M cash flow against audited financials and tax returns, because everything here is stated by the seller and the broker frames a $440M deal as a main street business, which is a credibility flag. Do not proceed past an LOI without QoE-grade financials and a facility-by-facility P&L.
Scrutinize payer mix and the split between in-network and out-of-network billing, since heavy out-of-network dependence exposes the buyer to payer clawbacks, reimbursement cuts, and No Surprises Act constraints. This is the most likely place for reported cash flow to prove unsustainable.
Examine all physician arrangements for Stark Law and Anti-Kickback compliance, including ownership syndication, medical directorships, and referral relationships. Regulatory exposure in ASC physician deals can create material successor liability and must be quantified before close.
Confirm state licensure, accreditation status, certificate-of-need where applicable, and lease terms for each of the 11-12 leased facilities. Since real estate is not included, understand rent, renewal options, and landlord relationships that could disrupt operations post-close.
Assess surgeon concentration to determine how much of the case volume flows from a handful of key physicians who could leave or take referrals elsewhere. Retention agreements, non-competes, and equity alignment for top producers are essential to protecting the earnings.
Clarify the exact corporate structure and what is actually being sold, given the vague 11-to-12 center count and the requirement to sign an NDA before location disclosure. Ambiguity about which entities, assets, and liabilities transfer is a red flag that must be fully resolved.

Source

Originally listed on BizBuySell. View original listing →