Gastroenterology billing is inherently complex and demands a strategic approach, especially as many industry leaders report that gastroenterology is disproportionately impacted by pay cuts and restrictive payer practices.
Dr. Omar Khokhar, a gastroenterologist at OSF St. Joseph Medical Center in Bloomington, Ill., emphasized the broader implications of these challenges:
“Cutting reimbursement doesn’t make patients disappear. When we can’t provide care, those patients end up in emergency rooms with more serious conditions. It’s a short-sighted approach,” he said.
Here are eight strategies to optimize gastroenterology billing, based on insights from a blog post from billing company FC Billing:
1. Prioritize detailed documentation
Effective gastroenterology billing requires thorough and specific documentation. Key components include history of illness, signs and symptoms, medical necessity, care plan, specificity of diagnosis, complications and management plan, and comprehensive documentation to minimize claim denials.
2. Understand coding nuances
Gastroenterology CPT codes are specialized and frequently updated. Billing teams need to master the following: current CPT and ICD-10 codes, modifiers for bundled services, and ancillary and global services billing rules.
3. Analyze and address denials
Gastroenterology practices should establish efficient systems to manage denied claims. Explanation of benefits should be reviewed for incorrect or outdated codes, authorization requirements and missing documentation. Addressing causes of denials, staff training and effective workflow will reduce these denials.
Denials have become a growing issue for GI practices. Pankaj Vashi, MD, department head of gastroenterology and nutrition at City of Hope Chicago in Zion, Ill., expressed his concern.
"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," he told Becker's.
4. Ensure coverage verification
Many gastroenterology procedures require pre-authorization. Practices should confirm patients' coverage, preauthorization and referral requirements before providing services.
Verifying eligibility upfront reduces surprise billing, speeds up claim processing, and enhances patient satisfaction.
5. Streamline revenue cycle management
An efficient RCM process is critical to maintaining financial stability. Effective billing teams can increase claim submission success, monitor explanation of benefits and submit effective appeals for denials.
6. Stay updated on payer policies
Frequent updates to payer reimbursement policies can lead to delays if not proactively managed. Practices should take time to read emails from insurance companies regarding coverage changes and be proficient in policy reimbursements, payment rates for your state, and updates for Medicare, Medicare Advantage plans and Medicaid.
7. Leverage data to identify trends
Data can provide insights into billing trends, including denial causes, underpayment patterns, work-flow gaps and rate increase opportunities.
Despite these efforts, GI leaders remain frustrated by payers’ resistance to data-driven evidence. Dean Lehmkuhler, administrator at Northside Gastroenterology Endoscopy Center, described the uphill battle.
"The data on outcomes we share with insurers is the only evidence we can provide to demonstrate our quality of care. The frustrating part is that they don't listen," he said. "When I worked with multispecialty practices, I had more leverage. In GI, they just don't seem to see it as a priority because it's a smaller portion of their budget."
8. Consider outsourcing billing
Gastroenterology billing can often be complex amid evolving industry standards. Oftentimes outsourcing billing can reduce cost, improve accuracy and increase revenue.