Source Article: MedPage Today – Some Health Plans Automatically Downcode Office Visit Claims

As some payers incorporate automatic downcoding of submitted E/M codes into their policies the burden of proof shifts to the practices to appeal and justify submissions.   These adjustments are being made primarily at higher level codes and adjusting them down one level – 99214 -> 99213 for example.  Downcoding policies increase administrative burdens, delay reimbursements and reduce revenue – especially for independent practices with limited staffing.  

Several physician organizations are urging regulators to require clinical record review before any code adjustments are made, including justification for the adjustment.  For Urgent Care operators, which often rely on higher volume and smaller margins, these blanketed algorithm-driven adjustments can materially affect their bottom line.  Those most likely to be impacted are the centers not part of a larger multi-site group or health system as they won’t be in a position to fight these adjustments at scale.  

Urgent Care centers are perfectly positioned to improve access to care and divert unnecessary visits ending up in the emergency department, but if these operators are caught in the position of absorbing losses from payer downcoding or investing the time and money in appeals the incentive to accept higher acuity (but still UC appropriate) patients will decrease and ED diversion will increase. 

In the MedPage Today article linked above Anders Gilberg, MGMA’s senior vice president for government affairs, said in a statement. “Insurers are simply looking to profit off of overworked medical practices that don’t have the time and resources to appeal.”  Visit the link to see the other groups weighing in!