Payer reimbursement
William Chey, MD, president-elect of American College of Gastroenterology and chief of the GI division at Ann Arbor-based Michigan Medicine, told Becker’s that payer reimbursement policies are significantly limiting the adoption of new technologies, 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,'” he said “Then, they use it as rationale for denying coverage or providing an inadequate reimbursement for the practice’s expense and investment.”
Without changes in payer reimbursement policies, GI practices struggle to invest in technology that could enhance patient care. Artificial intelligence is a prime example, he said. While AI is demonstrating benefits in diagnosis and treatment, many gastroenterologists cannot integrate these advancements due to reimbursement challenges and a lack of clarity on what payers will cover, he said.
“We must come together to find a better solution to help bring innovative technologies to our patients,” he said. “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.”
Stark law
For gastroenterologists seeking to participate in ASCs, Stark law remains a significant obstacle, according to Neal Kaushal, MD, a gastroenterologist from Sonora, Calif.
“While Stark law has been beneficial in many ways in preserving the sanctity of the physician-patient relationship, it may be useful in the future to revisit portions of the law to better support physician involvement in ASCs,” he said.
The past year has seen a sharp rise in Stark Law enforcement. In 2024. There was a surge in whistleblower-driven Stark law enforcement, with seven major indictments contributing to a record-breaking 979 qui tam lawsuits. False Claims Act settlements and judgments reached $2.92 billion by the end of the federal government’s fiscal year on Sept. 30 — an increase from $2.79 billion in 2023 and the highest total since 2021’s $5.69 billion.
Many leaders feel reforming or repealing portions of Stark law could promote ASC growth, particularly in gastroenterology.
“Given that the GI industry — especially with respect to CRC endoscopic screening programs – is shifting dramatically toward the ASC environment, having physician input and buy-in will be essential in forming lasting partnerships between health systems, payers and patients across the GI care continuum,” he said.
Other GI leaders share this concern.
“Anti-self-referral laws like Stark law and anti-kickback statutes make it difficult — or even risky — for physicians to invest in or directly access ASCs, even when they know they can provide better patient outcomes at a lower cost,” Shakeel Ahmed, MD, CEO of Atlas Surgical Group in St. Louis, told Becker’s.
Prior authorization
Like many specialties, gastroenterology is grappling with the growing burden of prior authorization. Increasingly, payers require prior authorization for diagnostic and surveillance colonoscopy, as well as medications for conditions such as reflux disease, irritable bowel syndrome and irritable bowel disease, Dr. Chey told Becker’s.
“Sometimes, this is renamed something else, but the end result is that the practice’s burden is the same,” he said. “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.”
The impact on patient care is clear. According to Medscape’s “They’re Awful and Impede Patient Care: Medscape Physicians and Prior Authorization Report 2024,” 61% of physicians said that patients frequently abandoned a recommended treatment due to prior authorizations. According to another survey by the American Medical Association, 85% of physicians said they do not view payer-appointed “peers” as peers at all.
Efforts to reform prior authorization policies are underway. On Oct. 1, UnitedHealthcare launched its gold-card program, which allows qualifying providers to skip the prior authorization process for a number of procedure codes. Several GI-related codes were affected by the program’s launch, and some view the program as another version of prior authorization. Two key GI organizations, the American College of Gastroenterology and the American Gastroenterological Association, have expressed skepticism about the program.
“Prior authorization is a major barrier — it’s a lengthy process that delays care and adds administrative burdens,” Geogy Vennikandam, COO of Chicago-based GI Partners of Illinois, told Becker’s. “Plus, there are inconsistencies in criteria across payers, requiring us to file appeals and additional documentation.”
