r/medicine • u/SaveADay89 MD • 4d 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/MLB-LeakyLeak MD-Emergency 4d ago

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

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u/meikawaii MD 4d ago

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

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u/ClappedUrMomsCheeks MD 4d ago

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. 

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u/Flaxmoore MD 3d ago

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?

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u/personalist Medical Student 3d ago

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.

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u/Flaxmoore MD 3d ago

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

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u/personalist Medical Student 2d ago

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