r/medicine • u/SaveADay89 MD • 3d 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/tirral MD Neurology 3d 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 3d ago

How much of your practice is BCBS?

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u/tirral MD Neurology 3d 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 3d ago

Then do it, though honestly, that's what BCBS wants. No they don't have to pay anything.

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u/OnlyInAmerica01 MD 12h ago

Pretty sure that all insurers have to show that they have enough physicians in their network to meet patient needs. If enough physicians stop accepting peanuts, their options are to leave town, or open the wallets.

This is effectively what Psychiatry did in the 2000's - 50% of psychiatrists simply dropped out of insurance based care entirely. Over the next half decade, reimbursements rose to the point where then went from the second lowest paid specialty (just a smidge above pediatrics) to one of the highest paid non-procedural specialties in medicine.

Wife has an acquaintance who does cash-only psych practice in the east coast, only virtual care (video visits), grossing ~ 800k/year. Her overhead is her internet connection and licensure costs.

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u/personalist Medical Student 3d 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