Inside The Fight Between Doctors And Insurance Companies Over 'downcoding'

Aetna spokesperson David Whitrap said nan insurer “has an responsibility to show for due coding connected behalf of our clients and members,” and to “safeguard against fraud, waste, and maltreatment successful nan authorities programs we serve.”

“Evaluating nan appropriateness of level 4 and 5 codes helps america guarantee providers are billing for their services accordant pinch nationalist guidelines,” Whitrap said. He besides said that “only 3% of providers” are affected by nan costs policy, but did not explain really Aetna determines erstwhile providers are coding inappropriately.

A spokesperson for Cigna Healthcare said astir 1% of providers successful its web will beryllium affected by its upcoming downcoding policy, and “all person nan correct to petition we reconsider individual claims reimbursement decisions.”

Humana and Molina Healthcare did not respond to requests for comment.

“It’s going to worsen our diligent care”

Dr. Bobby Mukkamala, nan president of nan American Medical Association (AMA), described downcoding arsenic a “game” to amended insurers’ finances.

“It’s going to worsen our diligent care, but it’s going to amended their bottommost line,” Mukkamala said. “And that’s nan incorrect calculus to usage to amended wellness attraction successful this country.”

Momentum for automatic downcoding comes arsenic experts opportunity an inverse problem of “upcoding” is connected nan rise. Upcoding is erstwhile patients and plans are billed arsenic though a higher level of work occurred, for illustration erstwhile a measure is sent arsenic though you had an assignment pinch nan doctor, but you only ever saw a caregiver practitioner.

In 2021, nan Centers for Medicare and Medicaid Services called upcoding “a superior problem” and nan national authorities periodically brings improper billing cases, some criminally and civilly, against wellness attraction providers.

But nan AMA position is that automatic downcoding — arsenic opposed to insurers reimbursing for a little level of work aft reviewing further accusation from physicians — doesn’t person immoderate objective logic down it.

For instance, erstwhile you sojourn a expert for a sinus infection, nan expert typically sends your security a declare referencing 2 sets of codes, 1 that lays retired nan eventual diagnosis, and different that indicates nan level of work aliases complexity of nan visit. That level tin beryllium wished by nan magnitude of clip nan expert spends connected nan visit, aliases by nan complexity of nan aesculapian decision-making astatine play — fundamentally a rubric that takes into relationship things for illustration laboratory tests ordered, medications prescribed and curen options discussed — but each that’s included connected nan declare is nan code.

Downcoding based only connected that knowledge assumes that an agency sojourn for a definite group of diagnoses has a ceiling of complexity, sloppy of nan patient’s aesculapian history and nan realities of what really occurred during that visit.

That’s wherever nan AMA disagrees.

“‘Guilty until proven innocent’ infers that we’re successful a court, right? That I’m to person my chance to say, ‘This is why I did what I did. But erstwhile this isn’t announced and this is thing that happens successful nan background, this is simply a condemnation earlier there’s moreover a tribunal trial,” Mukkamala said. “I merit to cognize what you deliberation I did incorrect truthful I tin show you my sentiment of why it’s right.”

Since March, nan AMA has sent letters to Blue Cross Blue Shield, Cigna and AHIP calling retired nan insurers’ downcoding practices. None of nan organizations replied, nan AMA said.

The AMA sent a akin missive astir what it called Aetna’s “unjustified, blunt costs simplification tool” to Aetna’s then-chief aesculapian officer, Cathy Moffitt, successful July 2024. The AMA would not disclose Moffitt’s response, but Aetna’s argumentation does not look to person changed.

A 2024 trading flyer for Aetna’s “Claim and Code Review Program” does connection a glimpse astatine nan insurer’s financial calculus — touting an mean 6.4% simplification successful costs for employer wellness plans, aliases $1.6 cardinal successful savings for a scheme pinch 4,000 members.

‘Like breaking down Fort Knox’

Cheryl Crowder runs billing for a physician-owned believe group successful agrarian southeast Ohio.

For much than a year, she says her doctors person been many times downcoded by 2 security companies.

Hospitals often person nan use of robust billing teams that exist, successful part, to woody pinch specified reimbursement issues. But for mini physician-owned practices, downcoding tin beryllium arsenic overmuch of an administrative load arsenic a financial one.

“We person to transcript records, and do declare audits and supply that accusation to them,” Crowder said.

It tin besides beryllium costly. “We’re paying group overtime to do this work. Because we person 70-plus providers, and we person 8 billers. It’s a ton of work,” she said.

Like galore of nan doctors’ offices successful this article, Crowder’s believe group was told they could beryllium removed from a downcoding programme if they successfully overturned a definite percent of their appealed claims, but nan mechanics of really achieving that are hazy.

“At what constituent do we measurement that? Is it 3 months? Six months?” she said. “They couldn’t reply that.”

When doctors taxable claims to insurance, they'll bespeak nan level of work aliases complexity of nan visits.Daniel Lozada for NBC News

Crowder moreover considered ending her believe group’s statement pinch 1 of nan insurers earlier yet getting immoderate alleviation this summer.

In nan aforesaid clip framework that downcoding has go prevalent, different inclination is compounding nan problem, doctors said: nan disappearance of dedicated representatives astatine security companies, whom doctors could scope retired to successful lawsuit of costs issues.

“It’s for illustration breaking down Fort Knox,” said Kelly Sutton, a family medicine believe head successful Van Wert, Ohio.

In April, Sutton noticed Aetna was downcoding higher complexity agency visits. Then Anthem and Humana started doing it, too.

She estimates her squad is spending astir 4 hours a week connected appeals, and respective much poring complete archiving to spot what mightiness beryllium causing nan downcoding. But if location is simply a pattern, it remains elusive.

“I deliberation they should spot-check physician’s offices, but immoderate this algorithm is, it doesn’t look to person a rhyme aliases reason,” Sutton said.

‘That is not bully for patients’

Dr. Adrienne Hollander, a New Jersey-based rheumatologist, said erstwhile it comes to being downcoded by 1 of nan main insurers she accepts, she’s simply astatine their mercy.

“They don’t nonstop america a denial saying, ‘We don’t deliberation that this is appropriate.’ They conscionable automatically salary america less,” Hollander said.

Unlike Sutton’s practice, Hollander’s multiprovider rheumatology believe does person a typical astatine nan insurer that’s downcoding her.

“At slightest we person an email, a resource, that we tin spell to and beryllium like, ‘Hey, show america what’s going connected here.’ A batch of group don’t person that,” said Jennifer Buonavolta, nan operations head astatine Hollander’s practice.

Even so, Hollander said she’s been incapable to get retired from nether nan downcoding programme entirely.

“If we can’t hole this aliases renegotiate our contracts, past we extremity taking insurers,” she said.

Three years ago, her believe made nan determination to extremity accepting UnitedHealthcare complete a different group of reimbursement frustrations. “The problem is that that is not bully for patients, because there’s not a ton of rheumatologists,” she said.

This year, 2 states passed legislation regarding downcoding, some focused connected transparency.

But respective different attempts astatine authorities government person stalled, including bills successful Ohio and New Jersey that would person efficaciously banned automatic downcoding, and 1 successful Connecticut aiming to prohibit specifically AI aliases algorithm-based downcoding.

“There’s a break point, and it’s for illustration you either spot much [patients] and springiness them little clip aliases you conscionable springiness up. It’s exhausting,” Wagner said. Daniel Lozada for NBC News

The AMA precocious rolled retired a template downcoding measure for willing states.

Mukkamala said his superior interest is that what doctors are experiencing now is conscionable nan beginning. “When an security institution gets distant pinch thing for illustration this, different security companies wouldn’t astonishment maine a spot if they said, ‘Well, that’s a bully idea. We’re going to do that, too.’”

For doctors for illustration Sarah Jensen, it’s easy to consciousness hopeless. In nan past year, she’s sent letters to Missouri’s security commissioner, to nan CEO of Anthem genitor institution Elevance, and to nan American Academy of Dermatology. No 1 has been capable to connection relief.

The stock of doctors moving successful backstage practices has plummeted successful caller years, driven successful ample part by nan desire for amended reimbursement rates. Jensen is coming to nan reluctant conclusion that her days successful backstage believe might, too, beryllium numbered: She’s been talking to backstage equity astir trading her practice.

“It’s for illustration decease by a 1000 cuts,” she said.