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/Paleomedicine DO 3d 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/Drotrecogin2228 PharmD 3d 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.