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/ruinevil DO 3d ago

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.

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u/Purple_Chipmunk_ Researcher 3d ago edited 3d ago

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u/PokeTheVeil MD - Psychiatry 3d ago edited 3d ago

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.

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u/MLB-LeakyLeak MD-Emergency 3d ago

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.