Issue link: https://beckershealthcare.uberflip.com/i/1531804
17 GASTROENTEROLOGY Demystifying GI reimbursement challenges By Patsy Newitt G astroenterology 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 Explanation of benefits should be reviewed for incorrect or outdated codes, authorization requirements and missing documentation.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. "e data on outcomes we share with insurers is the only evidence we can provide to demonstrate our quality of care. e 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 oen be complex amid evolving industry standards. Oentimes outsourcing billing can reduce cost, improve accuracy and increase revenue. n US Digestive Health adds 19 providers By Claire Wallace Exton, Pa.-based US Digestive Health has added 19 advanced practice providers to its network of specialists. The APPs will practice at various US Digestive Health locations throughout Pennsylvania and Delaware, according to a Dec. 17 news release. USDH is one of the largest GI practices in the U.S., with more than 40 locations and over 250 providers across two states. The 19 APPs joining its team in 2024 include: Crystal Boyer, PA-C Elizabeth Camerino, PA-C Julia Colangeli, PA-C Jennifer Grim, CRNP Linda Haffelfinger, PA-C Gabrielle Hocker, PA-C Monique Junker, CRNP Margaret Krebs, CRNP Charles Mikulka, PA-C Gee-Sue Park, PA-C Julia Quigley, PA-C Alexandra Quinn, CRNP Jasmine Rodriguez, PA-C Gloria Schaeffer, CRNP Joan Taddei, PA-C Alexandra Thurston, CRNP Carrie Weiss, CRNP Brian Scott Winfield, PA-C Kristen Zima, PA-C n