Here are five reimbursement issues currently impacting gastroenterology:
Declining reimbursements
Leaders are voicing concerns as gastroenterology reimbursements continue to decline. Gastroenterology was one of 13 specialties that saw declining reimbursement rates despite higher volumes per beneficiary.
Unadjusted and adjusted average reimbursement for GI procedures dropped by 7% and 33%, respectively from 2007 to 2022, according to a study published in The American Journal of Gastroenterology. Reimbursements for colonoscopies and biopsies decreased 38% during that period.
In another study published in the Journal, researchers found reimbursements for an esophageal biopsy decreased 41% in hospitals and 32% in physician's offices from 2006 to 2023.
There's also the site of service disparity. In an ASC setting, the average colonoscopy costs $925, compared to $1,224 in a hospital outpatient department. Additionally, screening colonoscopies in the U.S. cost a total of $23.7 billion in 2021, the most recent available data for nationwide cancer screening costs.
"There is the well-known issue of decreasing reimbursement over time for procedures that already have existing CPT codes, and that too in the face of the post-pandemic increased demand, higher costs of doing business and staffing issues," Vivek Kaul, MD, gastroenterology professor at the University of Rochester (N.Y.) Medical Center, told Becker's last year. "In addition, a real challenge we are facing is the inability to get reimbursed for a host of relatively newer (but well-established) endoscopic procedures that have emerged in the last decade or so. Oftentimes, these are minimally invasive, transformational interventions for our patients that help reduce morbidity, length of stay and overall healthcare costs but are poorly reimbursed or not reimbursed at all, in some cases."
More reimbursement cuts are expected
Pay cuts will continue next year — CMS finalized a 2.83% physician pay cut in its 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System released on Nov. 1. The physician fee schedule conversion factor for 2025 is $32.35, down from $33.29 in 2024.
The Digestive Health Physicians Association released a statement July 16, when the rule was proposed, opposing the cut, saying it "follows years of negligible increases, freezes and a payment cut in 2024."
"This is unsustainable for our nation's medical groups, physicians and other health care providers," the statement said. "The effects of these cuts will be exacerbated in rural and underserved areas, which continue to face significant healthcare access challenges."
The cuts follow a larger trend of declining physician pay. CMS cut overall physician pay by 1.25% for 2024, and overall physician reimbursement amounts per Medicare patient decreased around 2.3% between 2005 and 2021 when accounting for inflation, according to a new study from the Harvey L. Neiman Health Policy Institute.
Colonoscopy payment loopholes stand in the way
There are also loopholes to colonoscopy reimbursements standing in the way of physicians and patients. According to a recent study, only 17% of patients pay nothing for their bowel preparation for screening colonoscopy and that almost half of patients are directed toward using non-FDA-approved, over-the-counter regimens.
Study leader Eric Shah, MD, a gastroenterologist at Ann Arbor-based University of Michigan, told Becker's the research identified a loophole where prescription drugs are tied to screening costs, and Medicare patients end up paying more.
"If patients have to pay out of pocket for the prep, it could lead them to delay screening, especially given the current economy," Dr. Shah said. "If someone puts off screening because of $19, that's a real problem. We need to reduce those barriers."
Another "loophole" in colonoscopy reimbursements is the fact that if a colonoscopy becomes diagnostic, patients can expect to pay 15% of the Medicare-approved amount for a physicians' services. In ASCs, patients may also pay a 15% coinsurance amount.
Prior authorizations
Prior authorizations and other administrative hurdles are creating barriers for gastroenterologists in providing patient care and securing reimbursements.
"No matter what kind of physician you are, prior authorizations are something that physicians are concerned about because of the amount of extra time required to take care of those phone calls," Benjamin Levy III, MD, a gastroenterologist at University of Chicago Medicine, told Becker's. "On average it takes about 20 to 30 minutes per prior authorization for a physician outside of their clinic time. So anytime we have to do that, we have to set up the prior authorization and frequently it requires talking with several different people at an insurance company just to set up the prior authorization."
Around 97% of providers have had delays or denials for necessary patient care due to prior authorization requirements, according to the Medical Group Management Association's 2023 "Regulatory Burden Report."
"The most challenging payer trends affecting ASCs right now are the policies that require prior authorization or advanced notification for colonoscopies and other relatively routine endoscopic procedures," Eugenio Hernandez, MD, senior vice president of clinical affairs for Miami-based Gastro Health, told Becker's. "While these policies place an additional administrative burden on ASCs, the bigger issue is that they could potentially harm patients because of limited, delayed or denied care."
Claims denials
Gastroenterology is one of several specialties facing an increase of claims denials from payers.
"My major concern regarding procedure reimbursement is continued increase in costs of doing procedures and denials from payers with decreasing payments, especially by government payers," Pankaj Vashi, MD, department head of gastroenterology and nutrition at City of Hope Chicago in Zion, Ill., told Becker's.
In 2024, 77% of respondents said that payer policy changes are happening more frequently, up from 67% in 2022, according to Experian Health's "2024 State of Claims" survey. Additionally, 67% of respondents said reimbursement times are increasing in 2024, compared to 51% in 2022.
Omar Khokhar, MD, a gastroenterologist at Illinois GastroHealth in Bloomington, told Becker's he is holding out hope that 2024 might see more successful payer negotiations.
"I would love to see payers and clinicians sit down at a table and have a conversation about the benefit of early endoscopy for diagnosis and screening," he said. "In particular, how EGD/colonoscopy can potentially prevent patient morbidity and decrease downstream cost to the healthcare system. Yes, endoscopy isn't cheap, but cancer is a bad diagnosis and is more expensive."