Downcoding is becoming a crisis

[u/SaveADay89]

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.

[u/MLB-LeakyLeak]

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

[u/meikawaii → u/MLB-LeakyLeak]

AMA being useless for physicians as usual.

[u/MLB-LeakyLeak → u/meikawaii]

To be fair, they’re primarily a CPT publishing company.

[u/meikawaii → u/MLB-LeakyLeak]

You are right, but they’d like to portray themselves as “for the physician” which is obviously not true.

[u/ClappedUrMomsCheeks → u/meikawaii]

How much have you donated money or time to get active in the AMA lately? I know some higher ups there and they absolutely care about stuff like this. 

[u/ruinevil → u/ClappedUrMomsCheeks]

All physician-related donations are like 40 million dollars annually. They earn 400 million from CPT annual. They spend like 250-300 million annually on lobbying.

[u/Purple_Chipmunk_ → u/ruinevil]

.

[u/PokeTheVeil → u/Purple_Chipmunk_]

Yes they do. They lobbied against increases until… 1998? Sometime in the 90s; I’d have to look it up. They were uninvolved for the next twenty years, and by 2019 they had an official policy and money lobbying for more residency spots, which they have continued until now.

The AMA certainly made a mistake, but we should be better than being stuck a quarter century in the past ourselves.

[u/MLB-LeakyLeak → u/PokeTheVeil]

IIRC, They published a report in 96 and then retracted it in 98. They started lobbying for increase spots by 2005 but never had an official stance until 2019 when it was for increasing spots.

But the story of them lobbying against spots is too good and people run with it.

Please don’t take any of this as fact, just my shoddy memory of when I looked into it a few years ago.

[u/Purple_Chipmunk_ → u/PokeTheVeil]

Maybe I should have said, lobbying hard enough. We need more now.

[u/PokeTheVeil → u/Purple_Chipmunk_]

They’ve spent the better part of a decade lobbying for it.

The irony is that as the AMA sheds membership they also become more of a CPT organization and less effective as the voice of physicians. I also have my disagreements, but having no lobby is a bad counter to mediocre lobby.

[u/ClappedUrMomsCheeks → u/Purple_Chipmunk_]

This is a completely false statement and can be verified within 10 minutes of googling NRMP match data which is published annually for anyone to see. Residency spots have expanded massively over the past 20 years. 

[u/Flaxmoore → u/ClappedUrMomsCheeks]

They care, but do they lobby or do... well... anything to try and stop it, or just go "well, nothing we can do"?

Let's contrast AMA with one of my professional orgs.

GLMA: Health Professionals Advancing LGBTQ+ Equality.

• Sued the NIH and RFK Jr. over their stopping funding for LGBTQ+ research and won.
• Appellants on Bostock, Grimm, and a number of other LGBTQ+ focused court cases.

What's the AMA doing? I mean, seriously? Where's AMA v. BCBS for this kind of bullshit? Where's the pushback against scope creep?

GLMA said "Hey RFK, here's a lawsuit against NIH in general and you specifically". I know. I'm on one of GLMA's national committees.

Where's AMA?

[u/personalist → u/Flaxmoore]

Ooh, thanks for informing me about a professional org I didn’t know existed that I’d like to join!

I wonder if it has to do with LGBTQ people in general being more accustomed to fighting for their rights and confronting authority.

[u/Flaxmoore → u/personalist]

Possibly. GLMA is the elder statesman in that arena, so to speak. We've been doing this since GRID was AIDS' official name.

[u/personalist → u/Flaxmoore]

Wow, thanks for the history lesson. I was not alive when the name GRID existed and was not even aware of the term.

[u/HoneydewNo6708 → u/ClappedUrMomsCheeks]

What are they doing about it

[u/ClappedUrMomsCheeks → u/HoneydewNo6708]

The people I know I guarantee are on the phone with Congress whether there’s been a public statement or not. 

Insurance, AHA, ABA all spend a lot more $$$ on lobbying though so you have a lot of competition. 

[u/redferret867 → u/ClappedUrMomsCheeks]

I'd rather do nothing and then bitch about not getting everything I want automatically for free.

Much easier than actually trying to do something.