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Health Plans | Utilization Management


EviCore’s Gastroenterology solution applies a uniquely comprehensive approach to help improve patient outcomes and control costs. We not only promote appropriate evidence-based use of endoscopic procedures via utilization management, we also provide site-of-care redirection to high-value, lower-cost facilities where appropriate, and help to close gaps in necessary preventive care through patient outreach as part of our Colorectal Cancer Screening Program.

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Services Covered

EviCore’s Gastroenterology solution covers the following services:

  • Upper gastrointestinal tract endoscopies: Esophagogastroduodenoscopy (EGD) and capsule endoscopy
  • Lower gastrointestinal tract endoscopies: Colonoscopy
  • Colorectal Cancer Screening Program
  • Endoscopy Site of  Care Redirection
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Clinical Guidelines

EviCore’s Gastroenterology solution maintains dedicated clinical guidelines which include contributions from a panel of community physicians and experts associated with academic institutions. Our guidelines are aligned with the following national and international societies:

  • American Society for Gastrointestinal Endoscopy
  • American College of Physicians
  • American College of Gastroenterology
  • American Gastroenterological Association
  • US Multi-Society Task Force on Colorectal Cancer
  • American Society of Anesthesiologists
  • Canadian Association of Gastroenterology
  • European Society of Gastrointestinal Endoscopy
  • European Helicobacter Study Group
  • European Society of Pathology
  • Sociedade Portugesa de Endoscopia Digestiva
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Colorectal Cancer Screening Program

This program is designed to help close gaps in care, reduce mortality related to colorectal cancers, and improve the quality of life for health plan members, as well as increase quality ratings such as NCQA HEDIS and CMS Star measures.

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Site-of Care Redirection

Directing care to appropriately credentialed, high-quality ambulatory surgery centers in the appropriate clinical circumstances results in significant cost savings to the health plan client as well as to the patient, in the form of reduced copays, deductibles, and premiums. Reducing member out-of-pocket costs and/or time commitments also results in enhanced patient satisfaction.

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Utilization Management of Upper and Lower Endoscopy

Reducing utilization of low-value and unnecessary endoscopic procedures enables the reallocation of wasteful health spending to more appropriate care and screening programs. Medical necessity review also results in a reduction in avoidable post-procedure morbidity as well as any downstream costs related to unnecessary procedures.

Frequently Asked Questions

EviCore has developed comprehensive guidelines for the management of endoscopy procedures. Utilizing our staff of board-certified gastroenterologists, we curate the most up-to-date published and peer-reviewed literature and society-endorsed guidance. We then translate this information into our proprietary evidence-based guidelinesMedical necessity determinations and peer-to-peer consultations are completed exclusively by our gastroenterology specialists, providing true peer interactions with providers and maintaining a record of demonstrated value with low abrasion. In addition, EviCore’s substantial presence in the medical benefit management market allows us to leverage our enterprise’s operational and technical infrastructure to meet market demand at an unparalleled scale.

The EviCore Consumer Engagement unit directly reaches out to our clients’ members to encourage participation in colorectal cancer screening. We encourage members to complete either an at-home fecal immunochemical test (FIT) or a screening colonoscopy, as appropriate for their individual colorectal cancer risk. Our success in getting members to complete these procedures can then support our client’s efforts to enhance their STAR or HEDIS ratings. 

EviCore helps patients get high-quality GI procedures at the most affordable location by educating providers about cost-effective facility options that meet rigorous quality standards. When possible, we also help educate patients directly about high-quality, affordable facility options that are convenient to their location, and even provide support with scheduling appointments.

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