NY/NJ Ambulatory Surgical Center Portfolio, 10-12 Tri-State Locations

$225.0M

Revenue

$55.0M

SDE

8.0x

Multiple

Subscribe Free

Read the full deal writeup

Get Free Access

Already a member? Sign in

Full Editorial Writeup

This is a portfolio of 10 to 12 ambulatory surgical centers spread across New York and New Jersey, each running 9,000 to 25,000 square feet in prime locations. The centers perform a broad mix of outpatient procedures across general surgery, orthopedics, pain management, spine, GI, ophthalmology, vascular, urology, ENT, gynecology, podiatry, and plastic surgery. Critically, the facilities accept both in-network and out-of-network insurance, which is where the outsized margins likely come from given the out-of-network reimbursement dynamics in the Tri-State market.

The combined operation generates roughly $225M in gross revenue and $55M-plus in owner cash flow, a ~24 percent margin that is strong for a multi-site clinical footprint. It runs with 110 employees (75 full-time, 35 part-time), an established executive management team, specialized surgeons, and on-site clinical staff. The founder is retiring after two decades and positioning this as an exclusive sale to healthcare operators, private equity, or venture buyers, with a strict NDA and proof-of-funds gate before location details are shared.

At $440M asking on $55M cash flow, this is an 8x deal that only makes sense for a well-capitalized platform buyer, a PE-backed ASC roll-up, or a hospital system seeking outpatient capacity. The scale, specialty diversity, and cash generation are real, but the entire thesis lives or dies on reimbursement durability and surgeon retention, both of which need deep verification.

Why we like it

Earnings quality is anchored by $55M-plus in cash flow on $225M revenue, a ~24 percent margin that is genuinely strong for a multi-site clinical business. Ambulatory surgical centers convert procedure volume into predictable, high-ticket reimbursement, and a diversified specialty mix (ortho, spine, GI, ophthalmology, vascular) reduces dependence on any single service line. The scale here is institutional, not mom-and-pop.
Durability comes from the demand itself: surgery is non-discretionary. Patients do not defer spine, GI, urology, or vascular procedures in a downturn, and outpatient ASCs continue taking share from higher-cost hospital settings on both payer and patient economics. Ten to twelve entrenched locations across dense NY/NJ metros create real geographic moat and referral network stickiness.
Market tailwinds are firmly behind outpatient surgery. Payers and Medicare have been steadily migrating procedures to ambulatory settings for cost reasons, and the Tri-State region has the population density and specialist supply to keep volumes high. This is exactly the asset category PE-backed platforms and hospital systems are consolidating right now.
Operator advantage is built in: the executive management team, surgeons, and clinical staff all stay in place, and the seller commits to full knowledge transfer. For a platform buyer this is a bolt-on that arrives turnkey rather than a fixer-upper, which materially shortens time to value and reduces integration risk versus building sites from scratch.

How to improve it

Audit the payer mix immediately and quantify how much of the $55M cash flow depends on out-of-network reimbursement. If out-of-network is a large driver, build a plan to convert high-value volume to in-network contracts at defensible rates to protect against the ongoing regulatory tightening around surprise billing and No Surprises Act enforcement.
Standardize and benchmark procedure volume, block-time utilization, and case profitability across all 10-12 sites. Multi-site ASCs almost always have laggard locations; reallocating surgeon block time and adding high-margin specialty cases to underutilized centers can lift consolidated cash flow without new capital.
Lock in the surgeons before close through retention agreements, equity or profit-share structures, and non-competes. The entire earnings base walks out the door with the physicians, so the first 90 days must convert loosely affiliated surgeons into contractually committed, aligned owners of the outcome.
Pursue add-on specialty service lines and higher-acuity cases now being approved for outpatient settings (cardiology, more complex ortho and spine). Adding CMS-approved procedures to existing licensed infrastructure is high-margin incremental revenue with minimal facility cost.
Build a physician referral and marketing engine, which the listing itself flags as untapped. Systematic referral development from primary care and specialists, plus direct-to-patient education on outpatient options, can drive volume into existing capacity that is already largely fixed-cost.
Tighten supply chain and implant purchasing across the portfolio. At $225M revenue, consolidating vendor contracts, negotiating group pricing on implants and disposables, and standardizing formularies can move margin points that flow straight to cash flow.
Formalize revenue cycle management and denial recovery. In ASCs, coding accuracy, prior authorization discipline, and denial workflow directly determine collections; a modest lift in net collection rate on $225M of billings is a large absolute dollar gain.

Diligence notes

Verify the reimbursement structure in exhaustive detail. Out-of-network billing can inflate margins temporarily but faces regulatory and payer pressure; you must model what cash flow looks like under a fully in-network scenario and stress-test the No Surprises Act impact. This single issue could swing the valuation dramatically.
Confirm the physician relationships and ownership structure. ASCs are frequently physician-owned or joint-ventured, and any Stark Law, Anti-Kickback Statute, or safe-harbor compliance gap is a deal killer. Understand exactly who owns what, who refers, and whether the surgeons are employees, contractors, or equity partners staying post-sale.
Scrutinize the $55M cash flow definition and quality of earnings. Cash flow labeled as SDE across a 110-person, PE-scale operation is unusual, so demand audited financials, distinguish owner add-backs from true EBITDA, and confirm the per-site $100M-$130M figures reconcile to the consolidated $225M. The 8x multiple only holds if the earnings are clean and normalized.
Validate licensing, accreditation, and Certificate of Need status for every site in both NY and NJ. Each state has distinct ASC regulatory regimes, and any lapsed accreditation, pending survey deficiency, or CON transfer restriction could impair or delay the transaction. Confirm all facility leases and their remaining terms since real estate is not included.
Investigate malpractice history, pending litigation, and insurance coverage across all locations. High-volume surgical operations carry material liability exposure, and undisclosed claims or inadequate tail coverage could become the buyer's problem post-close.
Pressure-test the seller's claim that management stays and operations are turnkey. Interview the executive team directly, confirm their retention intentions, and identify key-person dependencies. A retiring founder who was more central than the listing admits would leave a leadership gap at close.

Source

Originally listed on BizBuySell. View original listing →