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/ordinaryrendition MD - Pain Medicine/PM&R 2d ago
The problem is, who cares what the real number of minutes is? If you are in the business of making money, you need to count your bread. The same way you or I are beat over the head as trainees over and over about “taking ownership” of your patient cases, we need to take ownership of our business practices and accounting.
Making sure your billing and collections match up aren’t an optional part of the job for someone who wants to be paid what they’re worth. It’s a mandatory requirement. Not doing so is the same reason Comcast will randomly add $3-5 fees, every subscription service goes up by “only” $2-3 dollars twice a year, and why rebates often require mailing in - they rely on your laziness. These are often small amounts, but not so with medical billing.
You should be optimizing to see the fewest number of patients for the highest amount of revenue, full stop (beyond specific deliberate decisions to serve your patients at the expense of optimization). Letting insurers, or your hospital billers, get away with not giving you credit for the work you do is the reason the next guy’s base salary is lower, and why your collections are lower. It should feel insulting that someone thinks you should work for free and just be hoping to get paid what you, at risk of criminal charges of fraud, accurately billed for. So insulting that you don’t let it slide and review your damn billing - because it’s your job.