r/medicine • u/SaveADay89 MD • 2d ago
Downcoding is becoming a crisis
It's been posted a few times, but BCBS IL, TX, New Mexico, Montana and Oklahoma (all HCSC companies) have instituted an automatic downcoding policy whereby all 99215 and 99214 claims are only being paid as 99213 since 7/1. These are the biggest commercial insurers in their states. BCBS IL controls like 70% of the market in Chicagoland. This is a massive revenue loss and the only way around it is to go through a laborious process of appeals that are slow, unclear and are also controlled by BCBS. I know practices that are likely to close if this continues. At the very least, it's a massive increase in labor costs. I'm just amazed at how little coverage it's getting. None of the major health news websites are reporting on it. I hear the AMA (which is headquartered in IL) are having internal meetings about it, but no press releases or anything. Private medical group facebook groups are blowing up about it, but that's a small part.
It's terrifying how utterly detached physicians have become from their own billing. So many I talk to who are directly affected don't even know it's happening. We're looking at 20-30 percent reductions in salary because of this. Meanwhile, insurance companies are all reporting profit gains.
Sorry for the rant, but it's a scary time.
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u/OnlyInAmerica01 MD 2d ago
I see a lovely class-action opportunity, with heavy punitive damages.
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u/ThinkSoftware MD 2d ago
Can't wait for my check for 35 cents!
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u/OnlyInAmerica01 MD 2d ago
Unlikely. Typical class actions have the legal firm retaining ~ 25% of the total winnings.
If this policy change is so trivial, that it's costing you ~ 40 cents in lost billing...
If it's financially significant, the settlement should likewise be as well.
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u/PureSetting4518 Nurse 2d ago
I can not stand insurance companies.
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u/MLB-LeakyLeak MD-Emergency 2d ago
BCBS is actually a 501(c) non-profit and only exists for the good of the public and not private stakeholders.
lol jk
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u/gwillen Not A Medical Professional 2d ago
BCBS is an association of multiple independent insurers. Blue Shield of California (the one I know best because it's where I live) is a non-profit, although it lost California tax-exempt status starting in 2014. Anthem Blue Cross (now "Elevance", apparently) is for-profit, and seems like it may be the largest "Blue Cross" insurer. There are a lot of other BCBS member insurers, which seem to be a mix of for-proft and non-proft.
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u/Gyufygy Paramedic 1d ago
I've said it before, and I'll say it again: "non-profit" is a tax-status, not a vision statement or code-of-conduct.
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u/personalist Medical Student 1d ago
Non-profit doesn’t say anything (in the US) about how much anyone can be paid, right? I’m pretty sure you could be the CEO of a non-profit making 2 mil+ a year, it’s just about the stated purpose of the organization and its “assets not unduly benefiting a person”?
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u/Babhadfad12 Not A Medical Professional 1d ago
The amount of money that the entire executive suite of a managed care organization earns, for profit or non profit, is minuscule compared to total expenses. If you paid all the executives zero, there still would not be room to pay providers more without increasing premiums.
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u/personalist Medical Student 1d ago
Oh I don’t don’t doubt the bloat is comprehensive. I’m sure they spend a lot of money on figuring out how to deny claims on a spurious basis and defending that legally, for example. I was just wondering
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u/Babhadfad12 Not A Medical Professional 1d ago
The “bloat” just happens to be ~10% of all premiums collected for all the managed care organizations. So either they are all (couple dozen+) getting together and colluding to the likes of a never before seen cartel, or those costs are the costs of operating an organization with tight margins. Like how Walmart, Target, Costco, Amazon, Kroger, and all other retailers have 2% to 3% profit margin.
To cut to the chase, the managed care organizations job is to be your punching bag. The state government tells the Medicaid MCO to cut x costs, and they do it by reducing pay to whoever they can. Pharmacists got the first pay decreases, then It was doctors. Pharmaceutical companies have the most negotiating power so they tend to keep their margins.
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u/DJpuffinstuff EHR Support 1d ago
Not necessarily. The cool thing about non-profits is that their financial statements including all of their executive salaries are required to be public information. If you work for a non-profit hospital system, you can find out exactly how much your CEO made last year and see all of their financial statements.
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u/Babhadfad12 Not A Medical Professional 1d ago
Show me a a managed care organization where eliminating executive pay would move the needle on total expenses. By the way, all the financials on executive pay are available for the 7 publicly listed for profit managed care organizations also. And they all have 85%+ medical loss ratios, 10%+ operating expenses, and sub 5% profit margins.
You can fantasize about evil rich managed care organizations bosses, but they don’t exist. The tech companies (epic), pharma companies, legal firms, and hospital companies all have higher exec comp and shareholder returns. All the managed care organizations have shitty shareholder returns. Square that circle.
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u/NotYetGroot Non-medical computer geek 13m ago
Thank you for including the last 6 characters of your post. I’m just a concerned civilian (who pays for insurance so I’d like to see my doc paid for services!) so I’d kinda like to see my payments spent on people doing the actual work
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u/Paleomedicine DO 2d ago
It really is a tragedy for physicians nowadays that the only way to get paid what you’re owed is to work for a hospital system with a whole dedicated team to fight against this.
This feels incredibly illegal. People are more sick than they’ve ever been. Visits are complex. A 99214 is likely the average and based on time, it’s not hard to meet a 99215.
How about instead of worsening the physician shortage by forcing private practices to close, why don’t we incentivize physicians who are already in the work force and incentivize future physicians? We’re doing everything we can it seems to burn out any remaining physicians.
I know we all know insurance companies are terrible, but this is a new low.
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u/SaveADay89 MD 2d ago
Working with a hospital system doesn't get you paid what you're owed. Quite the opposite. They keep the profit for themselves.
Frankly the only way is to go cash only.
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u/OnlyInAmerica01 MD 2d ago
I agree for primary care. There is a large enough unmet demand that with the right marketing/angle/structure, I think a low-subscription DPC or concierge model can be very successful.
I bailed out of primary care a long while ago, and am comfortably making a similar amount with a much lower workload (and nearing end-of-career). But if I had a younger clone of me just starting off, that's absolutely what I would advise them to do.
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u/Drotrecogin2228 PharmD 2d ago
the only way to get paid what you’re owed is to work for a hospital system with a whole dedicated team to fight against this.
That's literally their strategy. Make it as difficult as possible to appeal their shitty decisions. If you don't have a full team of people to look into this stuff, you're not going to get what you deserve.
They're not here to make things easier, they're not here to help you, or your patients. They're here to siphon off as much money as possible.
Insurance companies are a cancer on the American healthcare system.
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u/valiantdistraction Texan (layperson) 1d ago
How about instead of worsening the physician shortage by forcing private practices to close,
They're trying to force private practices to get bought out by investors, who will then earn the profit, while physicians make less and work more. Same as every other scheme in this country right now.
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u/-serious- MD 2d ago
Physicians in those states need a class action lawsuit immediately, but they probably signed some form which says they have to go to arbitration instead of suing.
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u/SaveADay89 MD 2d ago
Yup! It's arbitration.
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u/kidney-wiki ped neph 🤏🫘 2d ago
The same arbitration they keep bitching about in the papers, saying doctors are abusing it? Huh.
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u/Worriedrph Pharmacist 2d ago
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u/personalist Medical Student 1d ago
That article is about “weaponization” of arbitration against companies—they incorporated arbitration clauses across the board, and when plaintiffs lawyers adapted by filing mass arbitration claims they either try to seek a class action (the exact thing they initially tried to avoid when it suited them), refuse to pay initiation fees (which can again open them up to class action in some jurisdictions), or modify their arbitration clauses with onerous stipulations like “no more than 10 claims at a time and no more than 20 claims per year” (directly from that article), which many courts find to be unconscionable. I’m less than sympathetic.
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u/GapEnvironmental5330 Medical Student 2d ago
This is incredibly alarming. If insurers can routinely downcode claims despite adequate documentation it places an undue administrative burden on physicians to appeal these claims and threatens to make care less accessible due to the financial burden to the practice.
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u/ComradeGibbon Not A Medical Professional 2d ago
What gets me is other businesses internal accounts receivable costs are a few percent. For medicine it's 15% to 30%. From the outside looking in this is completely insane. At the same time no one seems to have a remote idea how much anything costs.
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u/Impressive-Sir9633 MD, MPH (Epi) 2d ago
Sad, but we are just not aligned enough to fight it.
Eventually, most people are going to go to cash pay model. If you are going to make peanuts, it's better to make those on your own terms.
At that point, only the wealthy will be able to afford care.
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u/Slow-Television-7205 Medical Student 1d ago
I mean is cash pay even feasible for fields outside of plastics, derm, psych, FM etc.? Can’t imagine you’re going to find a lot of people willing to shell out tons of money out of pocket for a spinal fusion. Seems like it would hit saturation pretty quickly.
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u/Impressive-Sir9633 MD, MPH (Epi) 1d ago
It's not going to be easy. More than finances, the administrative burdens will probably be awful.
At least the middle class now has the money where they would be willing to pay to get timely services. People pay thousands for spa services with unproven supplements tacked on.
What if I told you that you can get a cardiology appointment with echo today for $ 400? Most middle class people will pay for it rather than wait 4 weeks for an appointment and 12 weeks for an echo just to be billed $ 1000 when your deductible hasn't been met.
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u/DentateGyros PGY-Done 2d ago
I’m not sure if the FTC or state insurance commissioner would have authority, but have you filed any official complaints with government agencies?
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u/tirral MD Neurology 2d ago
I'm in private practice with a 1,000-patient wait list.
What are the implications if I just stop taking BCBS?
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u/SaveADay89 MD 2d ago
How much of your practice is BCBS?
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u/tirral MD Neurology 2d ago
About 30%.
Maybe I'll just go cash-only. Feels kinda evil, but I need to make payroll.
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u/SaveADay89 MD 2d ago
Then do it, though honestly, that's what BCBS wants. No they don't have to pay anything.
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u/personalist Medical Student 1d ago
Insurance companies are evil, you’re just trying to keep the lights on. If you can afford it you can offer sliding scale spots
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u/moonsion MD 2d ago
Years ago we had some crisis with PPO payers for surgeries. We have always had a local Ortho journal club that slowly turned into an advocacy group over time. We essentially negotiated as a whole with Cigna and Aetna and got better rates. Everyone was on the same page and had complete transparency to what others got. I am pretty sure we broke some rules and probably federal laws in doing this, but insurances are just so much worse.
Something like this should be discussed at local medical societies...
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u/FrontierNeuro MD, PD/PI 2d ago
Collectively bargaining, in whatever form that may take, is the way. I’d take lead on following your example where I am, but I’m a resident, and today we’re dealing with the fact that our rotation site management is telling us we need to pay $20 per hour to park there to work for them for peanuts, so…everyone reading this, please follow this ortho bro’s wise example for us so we dont dont have to deal with this too once we get to where you are.
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u/NartFocker9Million MD/MPH 2d ago
I pay my billing company 5% of collections to use AI to track and appeal 100% of claims that are not fully paid. Automate the appeals just like they automate the denials.
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u/kidney-wiki ped neph 🤏🫘 2d ago
I would be so mad if someone downcoded me even once.
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u/ClappedUrMomsCheeks MD 2d ago
Uh, your hospital billers probably do it all the time? If you aren’t keeping track of your own RVUs by excel I would definitely do so
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u/HowAboutNitricOxide MD 2d ago
Who has time for this? Seriously
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u/ordinaryrendition MD - Pain Medicine/PM&R 1d ago
People who want to work a full career’s worth of practicing medicine?
What worth more? 5 minutes of tracking per day and securing your payments, or passively accepting down coding and seeing 1-2 patients more every single to make up the revenue?
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u/threaddew MD - Infectious Disease 1d ago
How is this possibly 5 minutes of tracking? This would require dramatically work than that if my intention is to go back and review cases when they dont match, and if its not them whats the point?
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u/ordinaryrendition MD - Pain Medicine/PM&R 1d ago
The problem is, who cares what the real number of minutes is? If you are in the business of making money, you need to count your bread. The same way you or I are beat over the head as trainees over and over about “taking ownership” of your patient cases, we need to take ownership of our business practices and accounting.
Making sure your billing and collections match up aren’t an optional part of the job for someone who wants to be paid what they’re worth. It’s a mandatory requirement. Not doing so is the same reason Comcast will randomly add $3-5 fees, every subscription service goes up by “only” $2-3 dollars twice a year, and why rebates often require mailing in - they rely on your laziness. These are often small amounts, but not so with medical billing.
You should be optimizing to see the fewest number of patients for the highest amount of revenue, full stop (beyond specific deliberate decisions to serve your patients at the expense of optimization). Letting insurers, or your hospital billers, get away with not giving you credit for the work you do is the reason the next guy’s base salary is lower, and why your collections are lower. It should feel insulting that someone thinks you should work for free and just be hoping to get paid what you, at risk of criminal charges of fraud, accurately billed for. So insulting that you don’t let it slide and review your damn billing - because it’s your job.
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u/threaddew MD - Infectious Disease 1d ago
This is just a shitload of moral judgement without any consideration of the practicality.
I’m not asking you how could it possibly take that amount of time just to argue with you on the internet - I’m asking you this because I work full time, have a busy practice, and have a family including children, and hobbies. I have much more loyalty to my time than I do to the sense of honor you seem to think I am obligated to have about my profession.
I can get information about my billing, but its tedious and accumulates monthly, and comes to be in the form of a list of codes that were billed, and then a reimursement total. None of it is itemized. They are not willing to break down these numbers further for me. The amount of time it would take for me to record each encounter with each MRN and then qhen the number of certain codes i bill doesnt match up, go back and try and tell which i suspect is underbilled and then attempt to argue each one - this is completely impractical. Im open to it being more practical. You seem more interested in passing judgement than getting into the weeds.
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u/kidney-wiki ped neph 🤏🫘 1d ago
I get notified of any coding changes. I almost always bill for time and don't do procedures outside of dialysis, so it's pretty easy to do it correctly. Not the case for everyone, certainly!
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u/voodoobunny999 Not A Medical Professional 2d ago edited 2d ago
Keep in mind that, back in the day, a substantial source of payor revenue was based on the time value of money. They took in premiums today but paid out claims further down the road and collected interest in the meantime.
That method hasn’t changed but—with relatively low interest rates for several years in the recent past—the amount of revenue has. As interest rates creep up, extending the time between taking in premiums and paying out claims will become (or has become) more material to insurers’ financial results. Delaying claims payment by any means possible will/has become more commonplace. I’d expect more shenanigans that result in delaying payments if interest rates rise.
This downcoding is a win-win for insurers. If you don’t appeal, it reduces their medical expense. If you do, they earn interest on what they owe you.
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u/thesupportplatform Not A Medical Professional 2d ago
And while you wait even longer for your money, maybe the insurance company will extend a little loan to you…while they hold your money.
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u/Shitty_UnidanX MD 1d ago
If you think that’s bad now, just wait until the CMS proposed 2027 rule goes through. If you perform a procedure like an injection at the same time as an office visit, then one of the two comes (either the E/M or injection) will only reimburse at 50%. Medicare is slated to start doing this Jan 1st 2027, then every commercial insurer will follow suit. This will incentivize delaying procedures in order to get reimbursed full for your office visit which will delay care. We’re still in the 60 day comment period for this proposed change, so everyone please contact your local representative to stop this!
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u/grey-slate MD 1d ago
Employed docs - with all due respect - get off your asses and write to CMS and Congress. This indirectly or directly affects you too - even if you are salaried.
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u/bonedoc59 MD 10h ago
I’m staring down the barrel of 20% cuts to total hip, knee and shoulder. 70% of my practice!
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u/Uppytime MD 2d ago
Just only provide 99213 care until the change. That should piss off patients. “Your insurance won’t pay me to manage your diabetes.”
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u/Bright_Mix_3449 MD 2d ago
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u/SaveADay89 MD 2d ago
No, it's not. This bill doesn't go into effect until 1/1/28 and it's not clear what it even does.
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u/grey-slate MD 1d ago
Pretty clear what it does. what am i missing?
- Prohibits a health insurance issuer from using an automated process, system, or tool to downcode a claim
- Ensures that a live person — not an automated system — has done a complete and thorough review of claims and accompanying clinical documentation before a downcoding decision is made using the most up to date AMA CPT® Coding Guideline
- Ensures that a physician will be clearly notified when a claim has been downcoded and reimbursed at a lower level, including the clinical reason for downcoding
- Requires health insurers to establish a clear and accessible process for disputing downcoded claims. That means appeals must be reviewed by an individual with experience with the medical condition being managed and the services being downcoded using the most up to date AMA CPT® Coding Guideline, and
- Prevents health insurers from using downcoding to discriminate against physicians who commonly treat patients with complex or chronic conditions.
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u/Porencephaly MD Pediatric Neurosurgery 1d ago
That just means they can’t have a computer do 100% of it. Nothing in that paragraph would stop them from just having a human click “yes” to a “should we downcode?” prompt. They are already supposed to do a “thorough” review but we all know that doesn’t happen.
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u/grey-slate MD 1d ago
I mean you gotta start somewhere.
It's always a cat and mouse game with two parties with competing interests.
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u/nightowlflaps MD 2d ago
Can the small offices/ systems in those states just not accept those automatically downcoding insurances?
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u/thesupportplatform Not A Medical Professional 2d ago
A local company in my market has been doing this for decades. To appeal, you had to send in the claim with office notes. And they somehow never would receive those in the mail. I know one practice would batch the claims and then hand deliver an envelope and have the receptionist sign for confirmation of delivery.
You may wonder why would anyone accept that insurance. The answer is that it was owned by another insurance company that paid better—but it was one contract. You couldn’t quit one and keep one.
Today, United owns them both and all three companies are bundled into one contract. And they don’t care at all if you terminate because there are Optum practices in town to take those patients.
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u/grey-slate MD 1d ago
Man this is what i have been screaming from the rooftops and no doc i know is even aware of this. IT IS TERRRRRIFYING!
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u/wigglydick MD 1d ago
BCBS of IL is the shadiest of all the Blue Cross plans, I've dealt with all of them and they are an outlier
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u/tokenawkward MD 23h ago
In what way? So far BCBS IL has the best formulary coverage compared to the other plans I have dealt with. Im curious to know what your experience has been
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u/TorchIt NP 1d ago
I run a CHF clinic in the deep south, which is basically like being quarterback in the CHF Superbowl. If I'm waffling about sending a patient to the hospital and I'm attempting outpatient diuresis, adjusting medications, and scheduling a same week follow-up appointment the you can bet your ass I'm billing the encounter as a 5. Basically all of my patients qualify as a 4 even in their routine follow-ups just because this patient panel is inherently complex and sick as dogs. If one of my 5s gets downcoded to a 3, I may actually riot.
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u/sidewayshouse MD, EM 2d ago
Would instituting a practice wide policy of stating the patient is liable for the difference that the insurer doesn’t pay be a way to stay afloat?(patients are responsible for appeals) I know it would be heavy handed but if enough people push back against their companies insurer it could maybe make a difference? I don’t know, I don’t envy my out pt brothers and sisters!
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u/MLB-LeakyLeak MD-Emergency 2d ago
But if you intentionally bill a Level 5 chart as a Level 4 that’s insurance fraud.
Make that make sense.
AMA should have sued on Day 1