From preauthorization headaches to reimbursement struggles, 10 leaders joined Becker’s to discuss the payer policies causing them the biggest concern.
Question: What payer policies or behaviors are currently causing you the greatest concern, and why?
Editor’s note: Responses were edited lightly for clarity and length.
Chacko Alappatt, MD. Medical Director of Arthritis and Osteoporosis Center of Southwest Ohio (Miamisburg): Several of the payers are requiring a chart note/records request before payment is sent. These instances are typically associated with high-dollar claims related to drug purchases which makes the delays in payments particularly frustrating. We are also seeing more “self-funded plans” and are getting a message from the payer that payment will only be made once funds are uploaded from the employer … again more delays in payments. Authorizations for in office treatments or procedures are getting more difficult and we have essentially stopped doing this verbally over the phone since an approval letter which takes two to three weeks often doesn’t match what the representative on the phone approved. Since we are seeing more patients switch to Medicare Advantage over traditional Medicare, we have had a number of denials or increased out of pocket costs for the same treatments that were covered under traditional Medicare. Finally, payers continue to request chart audits and regularly perform take backs well after payment is provided.
Maya Babu, MD. Neurosurgeon with Surgical Affiliates Management Group (Sacramento, Calif.): Denials of coverage for patients with dire diagnoses/prognoses. It is horrible to watch patients and their families with terminal diseases struggle to navigate insurance at the end of life.
Alan Bielsky, MD. Anesthesiologist at Children’s Hospital Colorado (Aurora): Ultimately, there just doesn’t seem to be an acknowledgement of our continued hard work. The cost of eggs goes up, my house payments go up and I work harder. I think that payers’ continued downward pressure on my earnings has really just dejected me and my colleagues. The payers seem to have capitalized on our good will and sense of calling, yet everyone is shocked when we all show signs of burnout.
William Chey, MD. President-elect of American College of Gastroenterology and Chief of Division of Gastroenterology and Hepatology at Michigan Medicine (Ann Arbor): In GI, insurers are using prior authorization as a cost management tool, requiring prior authorization for diagnostic and surveillance colonoscopy and for drugs used to treat diseases like GERD, IBS and IBD. Sometimes, this is renamed something else, but the end result is that the practice’s burden is the same. It is also frustrating that these policies, which are expensive and time-consuming, are implemented without any underlying data to support them. When insurers implement new prior authorization requirements, we never see data on over-utilization or examples of clinical guidelines not followed.
I also think some payer reimbursement policies are stifling innovation, particularly in the endoscopy suite. Providers are forced to work with payers individually for any reimbursement, and payers will often deem new technology as ‘emerging’ or ‘experimental.’ Then, they use it as rationale for denying coverage or providing an inadequate reimbursement for the practice’s expense and investment. Without a meaningful shift in payer policy around reimbursement for new technology, many GI practices will be unable to make capital investments that improve patient care. AI is a great example of this. While clearly still evolving, we are seeing the benefits of AI in the diagnosis and treatment of patients. A new survey from the AMA says 66% of clinicians reported using AI last year, up from 38% in 2023. Respondents not using AI dropped dramatically from 62% in 2023 to just 33% in 2024. These numbers will only increase in 2025 and beyond.
At a recent AI Summit hosted by the American College of Gastroenterology, attending clinicians and industry representatives agree that the lack of reimbursement, as well as clarity on what new technology insurers are willing to pay for, are significant challenges to both developing and integrating AI into clinical practice. We must come together to find a better solution to help bring innovative technologies to our patients. In the long run, AI has the potential to reduce healthcare costs, but we must first develop strategies to ensure that there is a pathway for physicians who use these technologies to be paid.
Antonio Hernandez Conte, MD. Immediate Past-President of the California Society of Anesthesiologists: There are multiple ways in which insurance companies have recently exhibited dangerous policy-making that directly harms patients, creates barriers to access to care, and explicitly denies fair compensation for physicians who have provided services. As physicians, we want to work with commercial payers as partners in the healthcare system, and we want patients to be able to access care effectively and efficiently without needless insurance obstacles, such as pre-authorization for well-established medical and surgical procedures. Anesthesiologists provide care in many different practice settings (i.e., hospitals, ambulatory surgery centers, free-standing surgery offices), as well as for surgical emergencies. Therefore, we care for ALL surgical patients 24 hours a day/seven days a week, regardless of their insurance coverage (or lack of coverage).
A reasonable request of insurance companies is that they negotiate with anesthesiologists and all physicians in good faith to secure fair market contracts and provide coverage for appropriate patient care. Insurance companies place patients at risk by second-guessing the need for our services and perioperative expertise. Additionally, insurance companies must avoid targeting anesthesia care with disruptive payment policies such as the recent Anthem BCBS “time limit” policy that was initiated in Connecticut and New York. Poorly advised policies related to anesthesia include No. 1, artificial time limits on payments for the full duration of anesthesia for a surgical service, No. 2, failing to recognize ASA patient physical status modifiers and No. 3, failing to recognize special patient circumstances.
Finally, physicians feel strongly that insurance companies should stop playing games with the federal No Surprises Act. Insurance companies began weaponizing “out-of-network” billing laws as early as 2017 when California passed AB 72 — the state’s own version of the No Surprises Act. Insurance companies have utilized the NSA laws by forcing physicians to become “in-network providers” and subsequently strong-arming anesthesiologists to accept unreasonably low reimbursement rates that are destabilizing the future of the specialty. These tactics place additional fiscal burdens on hospitals to support anesthesia services. Additionally, insurance companies continue to delay payments to physicians even when they lose a payment dispute under the NSA arbitration process, and the payments are deliberately withheld by weeks or months even when they are required under the law to pay within 30 days.
Harry Haus, MD. Family Medicine Physician (Erie, Pa.): Prior authorization should be open 24 hours a day not seven hours Monday through Friday. A few years ago, I had a patient die from an overdose because they could not pick up Suboxone on Saturday. It was a three-day holiday weekend, and I was only able to talk to prior authorization on Tuesday but he was dead. Also, prior authorization should be with a real doctor. The insurance payments now come bundled together so it is hard to tell what is going on. Insurance companies often pay doctors they own more than independents like me. Many insurance companies own hospitals and independent doctors are not allowed on staff.
Corey Koenig, MD. Anesthesiologist at Providence Anesthesiology Associates (Charlotte, N.C.): Payers continue to leverage the NSA and arbitration process in a continued effort to push down rates. Unfortunately, the rules are tipped in the favor of the payers and they have deep enough pockets to continue the process despite losing the vast majority of disputes. They are simply squeezing out those who don’t have the cash flow to participate in the costly and lengthy process. Until payers are forced to actually negotiate in good faith efforts to be in network, this entire process will only make the arbitration companies money and cost physicians money just to collect the money they are owed.
Virginia Schmidt, MD. Family Medicine Physician (Chicago): Payer policies causing the greatest concern include having to get preauthorization for specialist referrals before the patient can schedule an appointment. Even when the specialist is in-network according to the payer website, specialists still require preauthorization to make sure they will get paid. This requires a lot of clinic time and results in delay in care.
Brad Sorosky, MD. CEO of Desert Spine and Sports Physicians (Phoenix): Medicare physician reimbursement has declined 29% in inflation-adjusted terms since 2001, according to the American Medical Association, while hospital payments have increased above inflation. This disparity has three critical implications. First, it creates unsustainable financial pressure on physician practices, particularly independent groups. Second, it incentivizes hospital acquisition of physician practices, leading to market consolidation and higher healthcare costs. Third, it undermines cost containment efforts by shifting care to higher-cost hospital settings. These trends are compounded by burdensome prior authorization requirements that delay patient care and increase administrative costs. Without addressing these systematic payment inequities and administrative burdens, we risk further market consolidation and decreased access to high-quality, cost-effective physician services.
Jason Taub, MD. Neurosurgeon at Dallas Neurosurgical and Spine. The idea that patient care can be dictated solely by a certain payor policy. It is important that payors understand caring for patients requires individualized care. Despite peer-to-peer discussions, the payers continually fail to “individualize” the needs for each patient.
