The Gastroenterology Reimbursement Landscape
The procedure is the same. Where it's done — and who owns it — decides the margin.
In gastroenterology, the endoscopy suite is the economic engine — and the economics hinge far less on the CPT than on site of service, ASC ownership, and the anesthesia and pathology that travel with every scope.
A screening colonoscopy performed in a hospital outpatient department can carry a facility payment roughly twice that of the same case in an ambulatory surgery center — yet in the HOPD the facility margin accrues to the hospital, not the practice. When a physician-owned ASC performs the case, the group captures the facility contribution on top of the professional fee, and the anesthesia and pathology streams that accompany the scope become owned ancillary revenue rather than leakage to third parties.
Demand is structurally favorable: the recommended colorectal-cancer screening start age has moved to 45, expanding the eligible population, while screening colonoscopy carries no in-network patient cost-share and polyp removal during a screening exam is generally covered — though commercial screening-policy nuances still create denial and cost-share disputes. At the same time, noninvasive options such as stool-DNA testing compete for screening volume, private equity is consolidating GI into national platforms, and IBD biologic infusion faces buy-and-bill and white-bagging pressure. The same book of endoscopy can be worth materially more depending on how it is sited, contracted, and integrated — and that is precisely where Fulcrum works.
Illustrative composition. Replace with your confirmed figures before launch; reflects current CMS ASC/OPPS and commercial methodology and public payer data, 2024–2026.
