How to choose an anesthesia consultant for your hospital

At some point most hospital anesthesia relationships hit a moment that calls for a second set of eyes: a subsidy request that does not add up, a group threatening to leave, a request for proposals you have never run before, or a decision to bring anesthesia in house. Before you pick up the phone, it helps to know what a good consultant looks like, and what the wrong one costs you.

This is not a pitch for any one advisor. It is the set of questions we would want a hospital to ask before hiring anyone, including us.

When outside help pays for itself, and when it doesn't

Not every anesthesia issue needs a consultant. A routine renewal with an open-book group, solid OR data on your side, and a stable working relationship is often something your own finance and perioperative leadership can handle, especially if you have been through a renewal cycle before. Our ten questions to ask before you renew cover what to request, whether or not you bring in outside help.

Outside help tends to earn its cost when the stakes or the complexity rise:

• A subsidy demand with a deadline. You need someone who can build and defend a counter-model fast. Our first-30-days plan covers what that looks like.
• A threat to leave, or notice already given. Interim coverage, credentialing and payer enrollment are unfamiliar territory for most hospital finance teams.
• A request for proposals. Running a credible anesthesia RFP takes market knowledge most hospitals only need once every several years. Our RFP guide walks through the process.
• A change of groups. Changing anesthesia groups without a coverage gap involves credentialing, payer enrollment and retention questions that are easy to get wrong the first time.
• Insourcing. Deciding whether to employ your own anesthesia staff is a multi-year financial and operational decision, not a one-time calculation.
• A billing or collections concern. If a group's revenue cycle performance does not seem to match its subsidy request, someone needs to test the numbers who is not the group itself.

If none of those describe your situation, a consultant may still bring a useful second opinion, but the case is weaker. Ask what a consultant would do differently than your own team could, with your own data, before you sign anything.

Ask about conflicts of interest first

Before you ask what a consultant charges, ask who else pays them. Anesthesia is a small industry, and many firms that advise hospitals also sell services to anesthesia groups: staffing and interim coverage, billing and revenue cycle management, recruiting, or locum placement. Some earn referral fees from vendors they recommend. None of that automatically disqualifies a firm. It does mean you need direct answers before you rely on its advice.

Ask every candidate:

• Whose side are you on, and is that written into the engagement letter?
• Who else pays you: anesthesia groups, staffing companies, billing companies, locum agencies or vendors?
• Do you, or an affiliated company, provide anesthesia staffing, coverage or billing services to any group?
• Do you help anesthesia groups prepare responses to hospital RFPs?
• Could your recommendation create work for you or an affiliate? For example, would a recommendation to change groups, add staffing or switch billing vendors send business back to you?
• Will you name the types of clients you work with in this market, without disclosing confidential details?

The Institute of Management Consultants USA, a certifying body for management consultants, tells its members to disclose in advance any financial interest in the goods or services behind a recommendation, and to avoid conflicts of interest or their appearance, disclosing any that arise.¹ That is a reasonable floor for any consultant you hire, anesthesia or otherwise.

The clearest conflict is a firm that both staffs anesthesia and advises hospitals on staffing decisions. A recommendation to add coverage, change groups or expand a care team can also become new business for the firm making the recommendation. That does not make the advice wrong, but you should know the incentive is there before you weigh it.

What to expect from the engagement

A hospital-side anesthesia consultant should give you, before work starts:

• Scope and fee in writing. What is included, what is not, what triggers additional cost, and by when.
• Confidentiality and data security terms. Your OR schedule, subsidy history and case data are sensitive. If protected health information will change hands, federal privacy rules require a signed business associate agreement before a vendor can create, receive, maintain or transmit that information on your behalf.² Ask how the firm secures your data and what happens to it when the engagement ends.
• Who actually does the work. Ask for the names and backgrounds of the people assigned, not just the person who pitched the engagement. A firm with depth in only one clinical background brings a narrower view of a care-team question than one with experience across physician anesthesiologists, CRNAs and certified anesthesiologist assistants (CAAs), alongside finance and operations staff.
• A clear, early data request. A consultant who can tell you on the first call what they need, case volume by location, staffed hours, payer mix and collections, is one who has done this before.
• Deliverables your board can use. A model, a set of options and a recommendation, not a slide deck of industry trends.
• A willingness to say renegotiate, not switch. A consultant should be as ready to recommend you repair the current relationship as to recommend you replace it.
• Respect for your current group and its clinicians. The physicians, CRNAs and CAAs covering your rooms today are not the problem to be solved. A consultant who treats every negotiation as adversarial makes your next renewal harder, not easier.
• Coordination with your counsel, not a substitute for it. A consultant should handle the economics and the operating terms, and expect your healthcare attorney to review the legal provisions and the fair market value of anything you agree to pay under the resulting agreement.³ If a firm tells you that you do not need a lawyer, treat that as a warning sign on its own.

Guidance aimed at physician practices choosing a consultant makes two of these points from the buyer's side: define the problem and the scope before you talk to anyone, and ask specifically who will be doing the work, since the person who pitches the engagement is often not the person who staffs it.⁴

Fee structures, and the incentive built into each

Anesthesia consultants are typically paid one of three ways. None is disqualifying on its own, but each carries a different incentive, and you should understand it before you sign.

Structure	How it works	What to watch
Fixed fee	A set price for a defined scope of work	Work outside the defined scope may cost extra
Hourly or retainer	Billed by time, sometimes with a monthly cap	Little incentive toward efficiency unless the engagement is capped
Contingency or percentage of savings	Paid a share of whatever the consultant can show it saved you	Rewards the largest visible number, not always the best outcome

The contingency model deserves the closest look. It ties the consultant's pay to a number you can point to, and that appeals to boards. But a percentage-of-savings fee can also reward cutting coverage instead of fixing what is actually driving the cost. A consultant paid on savings has no financial stake in whether a room that runs light in the late afternoon should stay open for surgeon relations or patient access. It has a stake in the subsidy number going down.

Elsewhere in healthcare, federal auditors have flagged the same structural problem. Reviewing Medicare's contingency-paid Recovery Audit Contractors, the Government Accountability Office reported that providers believed the contingency fee itself created an incentive for auditors to be aggressive in flagging claims as improper.⁵ The mechanism is the one to watch for in any consulting fee: pay tied to a single number pushes behavior toward that number, whatever else it costs.

If you do use a contingency structure, define savings narrowly and in writing, tie payment to results sustained over a full year rather than a one-time cut, and ask what happens if a recommendation reduces cost but also reduces coverage, quality or clinician retention.

Questions to ask on the first call

1. Whose side are you on, and who is your client of record in this engagement?
2. Who else pays you, and do you or an affiliate provide anesthesia staffing, coverage, billing or recruiting services?
3. Do you help anesthesia groups respond to hospital RFPs?
4. What is your fee structure, and can you walk through a hypothetical invoice?
5. Who specifically will work on our engagement, and what is each person's clinical or financial background?
6. What data do you need from us, and how quickly can you start once you have it?
7. What will the final deliverable look like, and who is it written for: our board, our CFO, our medical staff?
8. Can you describe an engagement where you recommended against a group change, or against your own initial instinct?
9. How do you handle confidentiality, and what happens to our data when the engagement ends?
10. Will you work alongside our healthcare counsel, or do you expect to handle legal review yourselves?

Red flags

• A savings number before they have seen your data. No one can responsibly estimate what a subsidy or contract should look like before reviewing your case volume, staffed hours and payer mix.
• One clinical model, every time. A consultant who recommends the same care-team structure or staffing mix regardless of your volume, geography or clinician supply is applying a template, not an analysis.
• A method they cannot explain. If you cannot follow how a recommended number was built well enough to defend it to your board, do not present it to your board.
• Silence on other clients' types. A firm should be able to tell you, without naming names, whether its other clients include anesthesia groups, staffing companies or billing firms.
• A push toward their own staffing or billing services. If the recommendation at the end of an engagement is to hire the consultant's own staffing arm or switch to its billing platform, ask why that option surfaced last instead of first.

What to do next

• Name the specific decision you need help with: a renewal, a threat to leave, an RFP, a transition, insourcing or a billing question.
• Ask every candidate the conflict-of-interest questions above before you discuss fees.
• Get scope, fee structure and confidentiality terms in writing before any data changes hands.
• Loop in your healthcare counsel early, not after a recommendation arrives.
• Decide, in advance, what your own team can pull internally, so you know exactly what you are paying a consultant to do.

Sources

1. Institute of Management Consultants USA, "IMC USA Enforceable Code of Ethics," IMC USA, reaffirmed March 2018. https://www.imcusa.org/about/ethics/code-of-ethics/ ↩

2. Kim Stanger, "Business Associate Agreements: Requirements and Suggestions," Holland & Hart LLP Health Law Update, October 2023. https://www.hollandhart.com/business-associate-agreements-requirements-and-suggestions ↩

3. Rachel Carey and Elizabeth Sullivan, "Success in Anesthesia Agreements: Key Strategies for Effective Anesthesia Contracting," McDonald Hopkins Insights, August 2025. https://www.mcdonaldhopkins.com/insights/news/success-in-anesthesia-agreements-key-strategies-for-effective-anesthesia-contracting ↩

4. Lisa Warren, "How To Choose a Healthcare Consultant," AAOS Now, American Academy of Orthopaedic Surgeons, October 2019. https://www.aaos.org/aaosnow/2019/oct/managing/managing01/ ↩

5. U.S. Government Accountability Office, "Medicare Recovery Audit Contracting: Weaknesses Remain in Addressing Vulnerabilities to Improper Payments, Although Improvements Made to Contractor Oversight," GAO-10-143, March 2010. https://www.gao.gov/assets/a302564.html ↩