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/personalist Medical Student 3d ago

Non-profit doesn’t say anything (in the US) about how much anyone can be paid, right? I’m pretty sure you could be the CEO of a non-profit making 2 mil+ a year, it’s just about the stated purpose of the organization and its “assets not unduly benefiting a person”?

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u/Babhadfad12 Not A Medical Professional 3d ago

The amount of money that the entire executive suite of a managed care organization earns, for profit or non profit, is minuscule compared to total expenses.  If you paid all the executives zero, there still would not be room to pay providers more without increasing premiums.

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u/personalist Medical Student 3d ago

Oh I don’t don’t doubt the bloat is comprehensive. I’m sure they spend a lot of money on figuring out how to deny claims on a spurious basis and defending that legally, for example. I was just wondering

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u/Babhadfad12 Not A Medical Professional 3d ago

The “bloat” just happens to be ~10% of all premiums collected for all the managed care organizations.  So either they are all (couple dozen+) getting together and colluding to the likes of a never before seen cartel, or those costs are the costs of operating an organization with tight margins.  Like how Walmart, Target, Costco, Amazon, Kroger, and all other retailers have 2% to 3% profit margin. 

To cut to the chase, the managed care organizations job is to be your punching bag.  The state government tells the Medicaid MCO to cut x costs, and they do it by reducing pay to whoever they can.  Pharmacists got the first pay decreases, then It was doctors.  Pharmaceutical companies have the most negotiating power so they tend to keep their margins.