The payer behavior making gastroenterologists wary

Here are three major payer moves and tendencies that have drawn gastroenterologists' interest in 2023:

1. UnitedHealthcare's advance notification

Gastroenterologists are calling on UnitedHealthcare to reverse its advance notification program, which went into effect earlier this year. 

According to a letter penned by the American Gastroenterological Association and 17 patient advocacy organizations, the policy "threatens to disrupt its 27.4 million commercial beneficiaries' access to virtually all endoscopies and colonoscopies."

2. Anesthesia coverage restriction for GI procedures

Blue Cross Blue Shield Massachusetts announced that Jan. 1, it will no longer cover the use of monitored anesthesia for certain gastrointestinal patients undergoing endoscopic, bronchoscopic or interventional pain procedures. 

The payer no longer will consider the use of monitored anesthesia medically necessary for these procedures unless a patient receives documentation by the operating provider that there are specific risk factors or significant medical conditions. 

3. Payer reimbursement negotiations

Some gastroenterology leaders said they are having a hard time securing appropriate reimbursement for GI procedures. 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," Dr. Khokhar 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."

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