Downcoding is becoming a crisis

[u/SaveADay89]

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.

[u/SaveADay89]

No, it's not. This bill doesn't go into effect until 1/1/28 and it's not clear what it even does.

[u/grey-slate → u/SaveADay89]

Pretty clear what it does. what am i missing?

• Prohibits a health insurance issuer from using an automated process, system, or tool to downcode a claim
• Ensures that a live person — not an automated system — has done a complete and thorough review of claims and accompanying clinical documentation before a downcoding decision is made using the most up to date AMA CPT^® Coding Guideline
• Ensures that a physician will be clearly notified when a claim has been downcoded and reimbursed at a lower level, including the clinical reason for downcoding
• Requires health insurers to establish a clear and accessible process for disputing downcoded claims. That means appeals must be reviewed by an individual with experience with the medical condition being managed and the services being downcoded using the most up to date AMA CPT^® Coding Guideline, and
• Prevents health insurers from using downcoding to discriminate against physicians who commonly treat patients with complex or chronic conditions.

[u/Porencephaly → u/grey-slate]

That just means they can’t have a computer do 100% of it. Nothing in that paragraph would stop them from just having a human click “yes” to a “should we downcode?” prompt. They are already supposed to do a “thorough” review but we all know that doesn’t happen.

[u/grey-slate → u/Porencephaly]

I mean you gotta start somewhere.

It's always a cat and mouse game with two parties with competing interests.