Gastroenterologists are facing mounting challenges as they navigate payer policies, diminishing reimbursements and administrative hurdles.
Leaders say these frustrations are not only impacting physician morale but also threatening patient access to timely, quality care.
Here are are five pressing concerns GIs have with payers:
1. Reimbursement declines
Gastroenterology, like many other specialties, has experienced significant cuts in reimbursement over the years — GI 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.
Dr. Omar Khokhar, a gastroenterologist at OSF St. Joseph Medical Center in Bloomington, Ill., highlighted the downstream consequences: "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.
These cuts will likely continue. Recent moves by CMS, including a 2.83% cut to physician payments in 2025, have only deepened concerns, with physician groups warning that quality of care will suffer if this trend continues.
2. Lack of payer engagement
Many GI leaders express frustration over payers’ apparent disregard for data demonstrating the value of GI care. 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."
Additionally, unlike larger, multispecialty practices that can leverage their size in negotiations, standalone GI practices often struggle to gain traction with payers.
3. Prior authorizations
Prior authorizations are a universal pain point for physicians, and GI specialists are no exception. According to Medscape's "'They're Awful and Impede Patient Care': Medscape Physicians and Prior Authorizations Report 2024," 86% of physicians feel that the time they spend processing prior authorization requests or appealing denials has led to delays in patient care. Another 61% said that patients frequently abandoned recommended treatments due to prior authorization delays.
"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."
The cumulative time spent on these administrative tasks pulls physicians away from direct patient care, adding to the growing burnout crisis in healthcare.
4. Colonoscopy reimbursement barriers
Reimbursement loopholes for colonoscopies are another source of frustration. A study led by Eric Shah, MD, of the University of Michigan found that nearly half of patients are steered toward non-FDA-approved bowel prep regimens, with only 17% avoiding out-of-pocket costs entirely.
Dr. Shah 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."
5. Rising claims denials
Claims denials are on the rise across gastroenterology, compounding the financial strain on practices. Dr. Pankaj Vashi from City of Hope Chicago pointed out the dual challenge of rising procedural costs and increasing denials.
"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.