The Role of Insurance in the Financial Health of Gastroenterology Practices

Most gastroenterologists find it hard to answer the question, “Is my practice financially healthy?”. With declining reimbursements, complicated regulations, and growing patient responsibility, maintaining the business side of the healthcare practice can be difficult. However, the good news is that the right combination of technology and services can help.

As a result of an intense advocacy effort led by the American Gastroenterological Association, CMS has expanded the regulatory definition of “colorectal cancer screening tests” and will waive cost sharing for follow-up colonoscopies after a positive stool-based screening test, as reported by the Medicare Physician Fee Schedule for 2023 (MPFS). This means that eventually, the patient’s financial responsibility will be eliminated by 2030: between 2023 and 2026, 15% of the cost is the patient’s responsibility; between 2027 and 2029, 10%; and by 2030, Medicare will cover the costs entirely. The rule, however, finalizes more than 4% in Medicare physician reimbursement cuts resulting from a decrease in conversion factor and expiration of temporary fixes passed by Congress. Together with a coalition of state and national medical societies, GI societies continue to urge Congress to prevent these cuts.

In this regard, insurance plays a critical role in the financial health of a healthcare practice, as it helps to ensure that patients can afford necessary medical care and that the practice can cover its costs. Below are some key points to consider when discussing the role of insurance in gastroenterology practices:

  1. Insurance helps cover the costs of treatments and procedures.

One of the primary roles that insurance plays in the financial health of a gastroenterology practice is that it helps cover the costs of treatments and procedures for patients. Gastroenterologists often perform expensive procedures such as colonoscopies and endoscopies, which can be cost-prohibitive for patients without insurance. Insurers can cover these costs, allowing gastroenterologists to provide necessary medical care to their patients without significantly burdening them financially.

  1. Insurance helps increase patient access to care.

Another important role that insurance plays in the financial health of a gastroenterology practice is that it helps increase patient access to care. Patients without insurance may be less likely to seek medical treatment as they may be unable to afford the cost of care. By using insurance to cover the costs of treatments and procedures, gastroenterologists can provide necessary medical care to a wider patient base, increasing access to care for those who may not otherwise be able to afford it.

  1. Insurance helps to stabilize revenue for the practice.

Insurance also plays a crucial role in stabilizing revenue for a gastroenterology practice. The cost of medical care can be unpredictable, and without insurance, a practice may experience fluctuations in revenue due to patients’ inability to pay for treatments and procedures. Gastroenterology practices, like all medical practices, have significant overhead costs, including staff salaries, rent, and equipment. By using insurance to cover the costs of care, a practice can better predict and stabilize its revenue stream.

With advanced technology and modern solutions, GI clinics can save a huge amount of time by automating key functions. Our expEDIum medical billing software, for example, can automatically verify insurance eligibility in real-time prior to the appointment with a gastroenterologist. The software has an in-built feature called Patient Payment Agreement (PPA) which allows users to pay their dues over a period as agreed by the provider. In addition, we do offer services such as Patient Responsibility Agreement (PRA) which allows staff to communicate efficiently with patients about how much money they should pay. By utilizing features like these, one can identify billing issues before patients arrive and ensure that the entire process is handled in a systematic manner. In our previous blog, we had mentioned that expEDIum’s billing software has reimbursed more than $160 million over the past 6-7 years, involving 80 clinics and 230+ providers submitting claims. During this period, over 600K+ claims were submitted for GI/Anesthesia/Ambulatory surgery, including HCFA-1500 and institutional claims. It may be easier to make an informed decision if you do a background check on solutions such as these and research their robustness.

In conclusion, insurance plays a crucial role in the financial health of a gastroenterology practice by helping to cover the costs of treatments and procedures, increasing patient access to care, and stabilizing revenue for the practice. With recent data showing an increase in the use of insurance in the healthcare industry, it is clear that insurance is an important component of the healthcare system and plays an important role in ensuring that patients receive the medical care they need.

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