Growing administrative burdens imposed by payors, including prior authorization requirements and shifting drug formularies, have reached record levels in gastroenterology practices, fueling widespread frustration.
“The issue of prior authorization requirements is something AGA and the entire medical community has been trying to get Congress and various administrations to take action on — with bipartisan support,” Kathleen Teixeira, AGA’s vice president of advocacy and practice, said in an interview with GI & Hepatology News. The problems, she said, are no mystery, ranging from administrative overload to delays in patient care. Still, “we just haven’t been able to make any progress, and Congress has been a little dysfunctional these days.”
To drive meaningful change, AGA is proactively engaging with national insurers to understand challenges and collaborate on solutions that reduce clinician burden and improve patient access. Since the fall of 2024, AGA has held discussions with major payors, focusing on streamlining prior authorizations, improving coding education, aligning medical policies with clinical best practices, and exploring value-based gastroenterology care models that focus on outcomes.
“We went into these meetings in the spirit of collaboration, and it’s been positive so far,” Teixeira said. “We view this as an opportunity to work together to alleviate some of these burdens, and I will say that hearing the perspective from payors has been very eye-opening.”
Following that spirit of collaboration, Teixeira recalled one meeting where payors shared the criteria needed for coverage decisions, and AGA officials explored ways to provide support. “We also went over our guidelines process, which has been very helpful so far in improving lines of communication,” Teixeira said. “We noted that we create an average of about four clinical guidelines per year and always have an open comment period. During this period, we welcome input from all stakeholders — including payors.”
More recent efforts include providing input to UnitedHealthcare on irritable bowel disease (IBD) formulary changes to prioritize patient experience and reduce red tape and raised concerns about the Care Gap Program — a joint initiative between Exact Sciences and insurers that sends Cologuard kits directly to patients. In a meeting with representatives from Exact Sciences, AGA shared key concerns, including disruption of the physician-patient relationship, risks of inappropriate referrals, and use of colorectal cancer screening intervals that may contradict established guidelines.
"I think we're slowly getting to the point where our communication is bi-directional, so if payors are looking for experts on something they're grappling with, they reach out to us," Teixeira said.
In August 2025, AGA launched the Payor Resource Center to equip members with tools to challenge payor denials, beginning with IBD and expanding to other disease areas. “We’re hoping to gather real-world data that can help inform future coverage decisions,” she said of the resource center. “One of our goals is to co-create solutions that work for gastroenterologists and their patients.”
In another development, AGA is partnering with data analytics company Latica to generate real-world evidence on guideline impact and patient outcomes. The goal is to use this data to inform future coverage decisions, demonstrate the effects of therapies in actual practice, and support potential value-based care or alternative payment models.
“This effort is also helping to correct the misconception that payors have complete knowledge of clinical practice, highlighting the value of accurate physician-provided data,” Teixeira said.
