Premier Tri-State Surgical Centers, 11+ ASC Portfolio, NJ/NY

$230.0M

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

Premier Tri-State is a portfolio of 11 to 12 ambulatory surgical centers spread across New Jersey and New York, each ranging from 9,000 to 25,000 square feet. The centers deliver a broad menu of outpatient surgical specialties including general surgery, orthopedics, pain management, spine, podiatry, GI, ophthalmology, vascular, urology, ENT, gynecology, plastic surgery and pediatric ENT. The operation runs on 310 employees, an established executive management team, specialized surgeons and full on-site clinical staff, positioning it as a fully staffed, manager-run enterprise rather than an owner-dependent practice.

The business reports roughly $230 million in gross revenue and $55 million in net cash flow, with the seller stating combined NY and NJ locations each generate between $100 million and $130 million annually. The centers accept both in-network and out-of-network insurance and are described as adaptable across diverse payer models, which is central to both the upside and the risk here. Out-of-network billing can drive outsized margins but is also the part of the healthcare reimbursement landscape most exposed to payer clawbacks, regulatory change and No Surprises Act pressure.

At a $440 million ask against $55 million of cash flow, this is an 8x deal aimed squarely at private equity, strategic healthcare acquirers and family offices with real capital. The founder is retiring after two decades of ownership and is offering a turn-key platform with management continuity. This is not an operator-buyer deal; it is an institutional roll-up candidate where the buyer is underwriting physician relationships, payer mix durability and regulatory compliance more than day-to-day operations.

Why we like it

Earnings quality is substantial on paper: $55 million of net cash flow on $230 million of revenue is a ~24% margin, which is healthy for a multi-site ASC platform. Ambulatory surgical centers are among the more attractive healthcare assets because they capture facility fees on high-margin outpatient procedures that continue to shift out of hospitals. The scale here (11+ centers) means no single location dominates the P&L.
The service is genuinely recession-resistant: surgical care for orthopedics, spine, GI, urology and ophthalmology is demand that does not disappear in a downturn. Outpatient volumes are structurally growing as payers and patients push procedures into lower-cost ASC settings. That secular tailwind supports the long-term durability of the cash flow.
This is a manager-run business with an executive team, surgeons and full clinical staff already in place, so the buyer is not stepping into an owner-operator gap. The retiring founder offering complete knowledge transfer with management continuity is exactly the setup an institutional buyer needs to underwrite. The diversification across 12+ specialties reduces reliance on any single referral channel.
At 8x cash flow for a diversified, multi-state healthcare platform, the entry multiple is defensible if the earnings hold up under diligence. Strategic acquirers and PE-backed ASC consolidators routinely pay similar or higher multiples for physician-owned surgical platforms of this scale. There is a clear exit to a larger consolidator or an add-on to an existing platform.

How to improve it

Immediately map the payer mix by center and procedure, separating in-network from out-of-network revenue. Out-of-network billing carries higher margin but higher fragility, so building a plan to migrate a portion into predictable in-network contracts protects the base while lowering reimbursement risk. This is the single most important lever on cash flow durability.
Standardize billing, coding and revenue cycle management across all 11 to 12 centers on a single platform. Multi-site ASC groups often leak margin through inconsistent coding and denial management, and a centralized RCM function can recover several points of margin within the first year. This also produces the clean data an eventual acquirer will demand.
Analyze surgeon concentration and lock in physician alignment through equity or long-term medical directorships. In an ASC, the surgeons drive the case volume, so any founder-era relationships that walk out the door directly reduce revenue. Retention agreements and syndication economics should be in place before close, not after.
Benchmark supply chain and implant costs across specialties, particularly orthopedics and spine where implant spend is enormous. Group purchasing organization participation and vendor consolidation across 12 centers should unlock meaningful COGS savings given the combined volume. Even modest per-case savings compound heavily at this scale.
Pursue targeted volume growth in the highest-margin specialties by adding block time and recruiting additional surgeons into underutilized centers. The listing itself flags growth via advertising and better utilization, but the real lever is filling operating room capacity in the 9,000 to 25,000 square foot facilities you already own. Utilization gains fall almost entirely to the bottom line.
Build a de novo or acquisition pipeline to expand the platform footprint in adjacent Tri-State markets. With management and RCM infrastructure in place, each additional center leverages fixed overhead and increases the exit multiple by making the group more strategically valuable to a national consolidator. Roll-up momentum is what turns 8x entry into a premium exit.

Diligence notes

Scrutinize the payer mix and out-of-network exposure in extreme detail, including trends in reimbursement rates and any recent or pending payer disputes. The No Surprises Act and ongoing insurer pushback on out-of-network billing could materially compress the $55 million cash flow. Model a downside case where out-of-network rates normalize toward in-network levels.
Verify the financials independently: the description hedges with '11 to 12' centers and 'as per the seller' revenue ranges, which is loose language for a $440 million ask. Demand audited or quality-of-earnings-reviewed statements by center, confirm the exact number of operating centers, and reconcile the $230 million revenue against the seller's stated $100 million to $130 million per state. This is a $440 million check and every number needs to be sourced.
Confirm ownership structure, physician syndication and any legal or regulatory issues including Stark Law, Anti-Kickback compliance, licensing and Medicare/Medicaid certification. ASCs are heavily regulated and physician ownership arrangements are a frequent source of hidden liability. Any compliance defect could void reimbursement or trigger clawbacks that dwarf the purchase price adjustment.
Investigate the real estate arrangement, since the centers occupy 9,000 to 25,000 square foot facilities but the listing does not include real estate in the ask. Understand lease terms, related-party landlord relationships and whether the founder owns the buildings personally. Above-market related-party rents can artificially inflate the reported cash flow and need to be normalized.
Test surgeon and referral concentration by pulling case volume by physician across all centers. If a small number of surgeons drive a disproportionate share of the $230 million, their departure post-close is an existential risk. Confirm what retention, non-compete and alignment structures exist and whether they survive the transaction.
Vet the broker and process carefully given the informal presentation (gmail contact, phone-heavy outreach, '$200 Mil Plus' headline). For a transaction of this size, confirm the seller is genuine, has clean title to the entities, and is represented by counsel capable of executing an institutional deal. Insist on a data room and a structured process before committing diligence resources.

Source

Originally listed on BizBuySell. View original listing →