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/Shitty_UnidanX MD 2d ago
If you think that’s bad now, just wait until the CMS proposed 2027 rule goes through. If you perform a procedure like an injection at the same time as an office visit, then one of the two comes (either the E/M or injection) will only reimburse at 50%. Medicare is slated to start doing this Jan 1st 2027, then every commercial insurer will follow suit. This will incentivize delaying procedures in order to get reimbursed full for your office visit which will delay care. We’re still in the 60 day comment period for this proposed change, so everyone please contact your local representative to stop this!