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Endoscopy + infusion
GI-specific expertise
Certified GI coders
chart-level audits
All major payers
commercial, Medicare & MA
Underpayment recovery
on claims marked paid
The loss is not always in your denials. It is often in your deposits.
While your team handles visible problems like prior authorization for Stelara, ASC scheduling, and days in AR, a larger leak can happen inside claims that already cleared. Payers process some claims below the contracted amount, and because the remittance says "paid," no one audits it.
Across the 42 GI revenue cycles we've analyzed, an average of 5.4–8.1% of gross revenue is withheld this way. For a $15M practice, that can mean USD 810K to USD 1.21M per year, and the loss compounds across every payer contract cycle.
See it on your claimsWhat 5.4–8.1% looks like on a $15M practice
The 5.4–8.1% range reflects OneMed's analysis of 42 GI revenue cycles; the dollar figures apply that range to a $15M example practice. Your actual exposure depends on payer mix, procedure mix, and documentation.
Five ways GI payments get quietly shortchanged.
GI billing is complex, and high-volume payer systems exploit that complexity. These are the underpayment patterns we find most often in claims already marked as paid.
Polypectomy downgrade
Payer systems scan operative notes for exact billing syntax; when the note says a polyp was removed but doesn't specify snare or EMR, the claim defaults to the lower-paying biopsy code.
Preventive-to-diagnostic fee-schedule shift
When a screening colonoscopy finds a polyp, the deductible should be waived under Modifier 33 or PT. Some claims are still processed on the lower diagnostic fee schedule instead of the preventive one.
Biologic NDC crosswalk & JW modifier drops
NDC-to-J-code conversions (mL to mg) using outdated tables can underpay units, and JW wastage lines are often zeroed for "missing documentation" even when it's charted.
Modifier 25 bundling erasure
A significant, separately identifiable E/M billed with Modifier 25 alongside a procedure gets bundled and zeroed by payer bundling edits.
MAC anesthesia time truncation
Time-based Monitored Anesthesia Care units get truncated toward the base rate when exact start/stop timestamps aren't captured in the anesthesia record.
Do not take our word for it. Check the fee schedule.
Take the most common trap. Under the published Medicare Physician Fee Schedule, a colonoscopy with EMR (CPT 45385) and one with a simple biopsy (CPT 45380) pay very differently. When an EMR is silently downcoded to a biopsy, the difference is pure lost margin.
If that downcode affects even 15 percent of a 4,000-colonoscopy year, that means 600 claims paid at the shortfall shown here. One issue alone can become a mid-six-figure leak. The numbers are public; you can check them yourself.
See it on your own claimsCPT 45385 (EMR) vs. 45380 (biopsy)
These are approximate national non-facility values. Confirm them against the current-year Medicare Physician Fee Schedule before publishing. The 15% × $132K figure above is an illustrative scenario; actual exposure depends on your volume and documentation.
This is an infrastructure gap, not a staff one
Your billing team is not failing. They are working against payer systems with stronger tools and more automation.
The "paid means paid" blind spot
Attention goes to $0 rejections. When a claim says paid, the file closes. No one rechecks thousands of colonoscopy payments against the operative notes.
No crosswalk verification
Re-checking NDC-to-J-code math on hundreds of biologic claims a month by hand isn't realistic for a standard billing team.
No E/M appeal workflow
When a payer zeroes out an E/M line, teams often record it as a bundling adjustment and write it off instead of appealing a legitimate separate visit.
We do not just chase denials. We find underpayments.
ClearView combines financial flagging with certified GI coder review, so underpayments are surfaced by the dashboard and verified by specialists. Payers lean on high-volume claim software; we counter with people who read the chart.
ClearView financial flagging
Our ClearView dashboard tracks payments and flags when a claim pays at the biopsy rate while that provider’s history supports the EMR rate. It shows the exact financial discrepancy in real time.
Expert clinical chart audit
Flagged claims route to our AAPC-certified GI coding experts, who read the operative note and find the clinical language that supports the correct code.
Targeted clinical appeal
We draft a documentation-backed appeal citing the exact op-note language, so the payer reverses the underpayment.
Payer pattern mapping
We track which payers underpay which codes and pursue systematic corrections, not just one claim at a time.
The 2026 OneMed GI Revenue Leak Index.
We don't rely on hypothetical math or isolated stories. We reviewed anonymized data from every GI revenue cycle we audited over the last 18 months. The pattern was clear.
42
GI revenue cycles audited
412,000+
claims audited
$6.21M
recovered for clients
90.7%
recovery rate on appeals
Of the $6.21M we recovered, here's where the money was hiding. Payer systems consistently underpay the highest-complexity GI claims. The leak is not random. It is part of the baseline.
| Underpayment pattern | Share of recovered value |
|---|---|
| Polypectomy downcoding | 34% |
| Biologic NDC & JW modifier errors | 28% |
| Modifier 25 bundling | 19% |
| MAC anesthesia truncation | 12% |
| Preventive-to-diagnostic shift | 7% |
Aggregated across OneMed GI underpayment audits over the trailing 18 months ($6.84M identified, $6.21M recovered). Individual results vary by payer, documentation, and contract terms.