ASC Billing Services Alert for GI Prior Authorization Expansion

Imagine running a busy gastroenterology practice and scheduling routine endoscopies at your ambulatory surgery center, only to find out an insurer won’t pay because you didn’t get prior authorization. This scenario is becoming more common. Health insurance payers are expanding prior authorization requirements for diagnostic GI procedures (like colonoscopies and endoscopies) performed in ASCs. This trend matters to GI practices because it directly impacts patient care and practice revenue. It’s changing how ASC billing services operate on a daily basis. In simple terms, prior authorization means you must get approval from the insurance company before doing certain procedures. If you don’t get this approval, the payer can refuse to pay.

In this blog, we’ll break down these changes in simple terms. We’ll look at what specific payers like UnitedHealthcare, and state Medicaid programs are doing with prior auth. We’ll explain how these new rules affect your ASC’s workflow, from scheduling a patient, to obtaining the pre-authorization, to billing the claim. You’ll also find technical tips about coding and what happens if you miss a prior auth. By the end, you’ll know why adapting to these changes is vital for GI practices and how specialized ambulatory surgery center billing processes or even an ASC billing company can help you keep your revenue on track.

Book ASC Billing Services & Forget Auth Problems.

Contact Us Today!

Why Prior Authorization for GI Scopes is Expanding

Prior authorization isn’t new, but its reach is growing in GI care. Traditionally, screening colonoscopies and common endoscopies were done as needed by physician recommendation. Insurers paid as long as the procedure was covered and medically necessary. Now, insurers are applying more oversight, especially for diagnostic (non-screening) GI procedures in outpatient settings like ASCs. Here are some reasons behind this expansion:

• Preventing Overuse: Insurance companies argue that too many endoscopies might be done without a clear need. UnitedHealthcare (UHC), for example, claimed that prior auth for GI procedures was intended to combat overutilization and avoid “unwarranted costs”. Internal data from payers suggested that up to one-third of upper GI endoscopies and half of non-screening colonoscopies for common conditions may not align with clinical guidelines. By requiring approval first, payers can review if a case meets medical necessity criteria.
  

• Site-of-Service Cost Control: Some payers are not just looking at how many scopes are done, but where they are done. ASCs are generally more cost-effective than hospital outpatient departments, and insurers prefer procedures to move to these lower-cost settings when appropriate. For instance, Aetna’s policy requires prior authorization for certain GI endoscopies only if they are scheduled at a hospital outpatient department – the same scopes done at an ASC or office do not need prior approval. This kind of rule nudges providers to choose ASCs (or office endoscopy suites) over higher-cost hospitals. In contrast, other payers like UHC applied new requirements across all outpatient sites (hospital or ASC) for diagnostic GI scopes. The bottom line is payers use prior auth as a lever to influence care settings and utilization.
  

• Data Gathering and “Gold Card” Programs: In some cases, insurers are introducing prior auth or notification not simply to deny claims, but to collect practice pattern data. UHC launched an Advance Notification process in mid-2023 for non-screening GI endoscopies, which it positioned as an alternative to prior auth. Providers had to submit patient and procedure details before performing esophagogastroduodenoscopies (EGDs), capsule endoscopies, and diagnostic or surveillance colonoscopies. UHC said no claims would be denied during this phase; instead, the data would be used to identify providers eligible for a 2024 “gold card” program. A gold card would mean a practice with a good track record wouldn’t need prior auth for these services in the future. However, the GI community saw this advance notice program as essentially a trial run for future prior authorizations, with concerns that it could ultimately lead to delays in care. In fact, UHC indicated that practices who don’t participate in the notifications would not qualify for any easing of auth requirements later. This shows how prior auth expansion is tied to bigger payer initiatives: collect data now, enforce controls later, and maybe reward the “compliant” providers by exempting them down the road.

Overall, the push for more prior auth in GI is a response to payer concerns about cost and appropriate use. But for GI practices, it means extra steps for each scope. Next, let’s see how different payers’ rules compare, because each has its own twist.

Payer Rules for GI Endoscopy Authorizations (Commercial & Medicaid)

Prior authorization rules can vary a lot by payer. It’s important for practices and ambulatory medical billing services to keep track of who requires what. Below is a comparison of how some major payer categories handle prior auth for GI endoscopic procedures in ASCs:

Table: Prior Authorization Requirements for GI Scopes by Payer

Commercial Requirements

No denial is issued in 2023 for lack of notification, but starting in 2024 UHC may use these notifications to implement a stricter prior auth or “Gold Card” system. Other Commercial Payers (Aetna, Cigna, Anthem, etc.) often required for diagnostic GI scopes in many plans. Specific rules vary. 

Aetna:

Requires precertification if a GI endoscopy (e.g. colonoscopy, EGD) is scheduled at an outpatient hospital (NOT required if done at an ASC or office). This encourages use of ASCs. 

Cigna:

Uses eviCore guidelines – many GI endoscopic procedures need prior approval under their utilization management programs for a provider’s proper ASC billing services process.

Anthem/BCBS:

Many Blue Cross plans also require prior auth for certain endoscopies or if done in costly settings (policies differ by state). Always verify by checking the insurer’s precertification list for CPT codes (e.g., colonoscopy CPT 45380, etc.). 

Medicaid (State Programs)

Yes, they are often required for most GI procedures, depending on state policy or managed care plan. State Medicaid programs and Medicaid managed care organizations typically require prior authorization for non-emergency outpatient procedures. For example, Florida’s Medicaid plan (through UHC Community Plan) lists upper and lower GI endoscopy codes like 43235, 43239, 43249 as requiring prior auth. Some states make exceptions for preventive services under federal rules (e.g., Early and Periodic Screening for minors, or screening colonoscopies for adults might be exempt). Always check your state Medicaid provider manual or the MCO’s auth list.

Expert Tip:

How Prior Auth Changes Impact ASC Workflows

Expanding prior authorization requirements means GI ASCs have to change their day-to-day workflow. It’s not just a billing issue at the end – it affects scheduling, patient prep, and documentation from the very beginning. Let’s break down how a typical ASC workflow is affected:

1. Scheduling and Patient Booking

In the past, when a GI physician decided a patient needed a colonoscopy or endoscopy, the office would schedule it at the ASC and tell the patient when to come in. Now, scheduling isn’t so simple. The ASC (or practice) staff first has to verify if the patient’s insurance requires prior authorization for that procedure.

• Insurance Verification Step: For every case, staff must check the patient’s insurance plan before finalizing the procedure date. This includes determining if the planned CPT code (for example, 45385 for colonoscopy with polypectomy) needs approval. If yes, you need to build in time to request and obtain that authorization before the patient can be seen. This may delay scheduling by days or even weeks if you must wait for the insurance’s OK.
  

• Patient Communication: Front-office staff also need to inform the patient about these requirements. At a 5th grade reading level explanation: “We have to get your insurance company’s approval before the test.” Managing patient expectations is now part of scheduling. Patients should understand that their procedure might be rescheduled if the approval isn’t obtained in time. This transparency helps avoid frustration if there are delays.
  

• Urgent Cases: What if the patient urgently needs the procedure? Most payers have exceptions for emergencies. For example, prior authorization is not required for emergency or urgent care in virtually all plans. If a GI procedure must be done immediately for a serious issue (like a bleeding ulcer), ASCs can proceed and sort out coverage after. Still, documentation must clearly show it was emergent. For non-urgent but time-sensitive cases (say a GI obstruction), insurers may offer expedited authorization if the provider indicates urgency.

Trust Professional ASC Billing Services & Reduce Scheduling Hassles.

Consult Experts Now!

2. The Prior Authorization Process (Pre-Procedure)

Once you identify that a planned GI endoscopy does require prior authorization, the ASC or practice must go through the process of obtaining it. This involves coordination between the physician’s office, the ASC scheduling team, and the billing staff (or ASC billing services team). Key steps include:

• Gather Medical Documentation: Insurance companies will want to know why the procedure is needed. The GI practice must prepare documentation such as the patient’s history, symptoms, diagnosis (ICD-10 codes), and any prior treatments or test results. For example, if a patient is getting an EGD for abdominal pain, you might need to show they tried medication first, or that they have alarm features justifying an endoscopy. Each payer has criteria; e.g., Cigna/eviCore might have a checklist of indications for approving an EGD. Preparing this info upfront is crucial. Missing info can lead to delays or a denial of the auth request.
  

• Submit the Request: The request is usually submitted via the payer’s online portal or by fax/phone. It includes patient details, the procedure code, planned date, facility (ASC), and the supporting documents. UnitedHealthcare’s new portal for advance notification, for instance, requires entering patient data for every GI endoscopy. Staff have noted that these portals can be confusing or time-consuming, so having well-trained ASC billing services or auth coordinators is important.
  

• Follow Up and Approval: After submission, the ASC must wait for a response. Some payers give instant approval if criteria are met, but many take a few business days. Medicare Advantage and commercial plans typically respond in around 5–7 days for non-urgent requests, per new CMS rules pushing for faster turnarounds. If you don’t hear back, staff should proactively follow up; lost or delayed auths are dangerous to your schedule.
  

• Handling Denials Before the Procedure: If the prior auth request is denied, that’s a red flag to stop and reassess. A denial means the insurer doesn’t agree the procedure is necessary as requested. The practice can appeal or peer-to-peer with the insurance’s physician reviewer, or provide additional info. Sometimes a tweak like clarifying the diagnosis can overturn a denial. However, if the insurer won’t budge, proceeding with the scope could mean no payment. In such cases, the physician might decide to cancel or delay the procedure, or the patient might choose to pay out-of-pocket if willing. These are tough situations that require careful communication. The goal is to avoid getting to this point by submitting strong documentation initially.

Hire Auth Experts for ASC Billing Services.

Contact Now!

3. Changes in ASC Billing and Claims Submission

The prior auth expansion also changes what happens after the procedure, during billing and claims submission. ASC billing teams (whether in-house or an external ambulatory surgery center billing and coding services provider) need to adjust their processes to ensure smooth claims:

• Including Authorization Details on Claims: When an ASC has obtained a prior authorization or notification number, that info often must be linked to the claim. Typically, electronic claims have a field for prior authorization number (or on a paper CMS-1500 form it’s Box 23). Not all payers require the number on the claim form, since they can match it behind the scenes, but it’s a good practice to include it where possible. It serves as proof that you followed the rules. Check each payer’s preference: some Medicaid programs, for instance, want the auth ID on the claim or they will automatically deny. Ensure your ASC billing software captures this.
  

• Using Correct Codes and Modifiers: Coding accuracy is more important than ever. The procedure performed must match what was authorized. If you got approval for a diagnostic colonoscopy (CPT 45378) but during the procedure the doctor also removed a polyp (CPT 45385), you need to update the code. Generally, this is fine – payers expect that biopsies or polypectomies may occur. However, you should list all applicable CPT codes and perhaps document that it started as a diagnostic scope. Modifiers might be needed in certain scenarios. 

For Medicare and some plans, when a screening colonoscopy turns diagnostic (polyp found), you append modifier -PT (for Medicare) to show a screening turned therapeutic. Commercial payers often use modifier -33 on preventive services. These modifiers don’t directly affect prior auth, but they ensure the claim is processed under preventive benefits if it started as a screening. Importantly, if a procedure was truly scheduled as a screening (which usually doesn’t need prior auth) but becomes diagnostic, insurers should not retroactively deny it for no auth. It was unscheduled that it became therapeutic. Still, to avoid any confusion, coding it correctly with modifiers is key.

• Payer Documentation Requirements: Along with the claim, some payers might require you to submit the operative report or pathology if the procedure was done without prior auth in an urgent situation. For example, if you marked the claim “emergency” and no auth, be ready to show why it was emergent (such as by attaching the procedure report indicating active bleeding). Most routine cases won’t need you to submit notes with the claim, but keep good records. If the insurer challenges the claim, you’ll need to provide documentation in an appeal.
  

• Denials for Missing Prior Auth: This is a critical area. If a claim is submitted for a GI endoscopy and the payer’s system finds no prior authorization on file, they will likely deny payment. These denials typically come with codes like CO-197 (which indicates “authorization required/not obtained”) or a similar remark. There is usually little recourse on such denials unless you can prove an exception. One strategy is to appeal by demonstrating that either (a) the service was exempt (e.g., it was a preventive screening or an emergency), or (b) you actually did get an authorization and it was a clerical error (in which case, provide the auth number and documentation). 

However, if it was simply an oversight and the procedure wasn’t authorized, appeals often fail and the claim will not be paid. According to a report from an ASC revenue cycle company, managing a denial after the fact is much harder than getting the approval upfront. In fact, trying to fix an unpaid claim due to no auth can take many staff hours (calling, writing appeals) and still result in lost revenue. This is why forward-thinking ASC medical billing processes put heavy emphasis on getting the prior auth before the patient is on the table. It saves a lot of pain later.

4. Post-Procedure Workflow and Follow-Up

After the claim is submitted, there are a few more workflow considerations:

• Tracking Auth Expirations: Many authorizations have an expiration or are valid only for a window of time (e.g., 30 days or 60 days from approval). If a procedure gets rescheduled outside that window, staff may need to request an extension or a new auth. A good practice in ASC billing services is to keep a log of active authorizations with their end dates. That way, if a patient postpones their endoscopy, you won’t forget that the auth might lapse.
  

• Monitoring Payer Policy Changes: This is an ongoing task. Payer rules for prior auth can update frequently. One month a certain code might need approval; the next month it might not, or vice versa. For example, UHC indicated they plan to remove about 20% of existing prior auth requirements across various services as part of reforms. But at the same time, they might introduce new ones in other areas. State Medicaid programs issue bulletins with updated lists annually or quarterly. Medicare Advantage plans send provider updates. The ASC billing services team should review these communications so nothing slips through. Many practices hold periodic meetings to review any authorization-related denials and update internal checklists for each payer.
  

• Increased Administrative Load: All these steps mean more work for your team. A survey found that 82% of healthcare providers (including those in ASCs) say prior auth is extremely burdensome. GI ASCs are feeling this burden through extra phone calls, paperwork, and coordination. This is essentially an unfunded mandate – payers don’t pay you to do auths, but you must invest time to get paid for the procedure. If not managed well, this can strain your staff and even affect patient care (since nurses or coordinators are busy with paperwork). Some ASCs have had to hire or dedicate specific staff (“authorization specialists”) just to handle the load. Others turn to external medical billing services or a revenue cycle management company for help in handling authorizations and denials. We’ll discuss more on that in a moment.
  

Conclusion: Stay Proactive and Informed

The expansion of prior authorization requirements for diagnostic GI scopes in ASCs is a significant shift that demands attention. It’s not “business as usual” for GI practices and ambulatory services in medical billing. Instead, it’s now an environment where every colonoscopy or endoscopy might come with an extra checklist and a waiting period for approval. While burdensome, these changes aim (at least from the insurers’ perspective) to ensure appropriate use of procedures and manage costs. For GI providers, the priority is to prevent these new rules from disrupting patient care or the practice’s livelihood.

To manage this, stay informed about each payer’s policies – they evolve constantly. Make sure your team knows, for each scheduled case, whether an auth is needed and gets it done. Build good relationships with insurance reps if possible, and don’t hesitate to advocate for your patients when auth decisions seem misguided. Finally, treat your billing workflow as a living process. Incorporate checks and balances for prior auth, use ASC billing services expertise as needed, and continuously educate both staff and patients. When done right, a GI practice can still thrive and provide timely care – with prior auth being just another box to tick off, rather than a roadblock.