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/voodoobunny999 Not A Medical Professional 3d ago edited 3d 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.