'Guilty until proven innocent': Fight between docs and insurers over downcoding
6 hours ago
- #healthcare
- #downcoding
- #insurance
- Dr. Terry Wagner's office manager noticed he was being underpaid by Aetna on higher-level claims without explanation, a practice known as 'downcoding'.
- Downcoding involves insurers automatically downgrading claims to lower reimbursement tiers without reviewing visit details, significantly impacting small practices.
- Doctors must appeal each downcoded claim individually, requiring extensive documentation and time, which is financially and administratively burdensome.
- Multiple insurers, including Anthem, Humana, and Cigna, have acknowledged or implemented downcoding practices, often using third-party vendors or AI to cut costs.
- Downcoding forces doctors to see more patients in less time, drop certain insurance plans, or sell their practices, negatively affecting patient care.
- The American Medical Association (AMA) criticizes downcoding as a financial tactic by insurers lacking clinical logic, worsening patient care while boosting insurer profits.
- Some states have passed transparency laws regarding downcoding, but broader legislative efforts to ban the practice have stalled.
- Doctors report losing thousands of dollars due to downcoding, with some considering leaving private practice due to unsustainable financial pressures.