'Guilty until proven innocent': Fight between docs and insurers over downcoding

Summary

Aetna spokesperson David Whitrap said the insurer “has an obligation to monitor for appropriate coding on behalf of our clients and members,” and to “safeguard against fraud, waste, and abuse in the government programs we serve.” “Evaluating the appropriateness of level 4 and 5 codes helps us ensure providers are billing for their services consistent with national guidelines,” Whitrap said. He also said that “only 3% of providers” are affected by the payment policy, but did not clarify how Aetna determines when providers are coding inappropriately. A spokesperson for Cigna Healthcare said approximately 1% of providers in its network will be affected by its upcoming downcoding policy, and “all have the right to request we reconsider individual claims reimbursement decisions.” Humana and Molina Healthcare did not respond to requests for comment.“It’s going to worsen our patient care”Dr. Bobby Mukkamala, the president of the American Medical Association (AMA), described downcoding as a “game” to improve insurers’ finances. “It’s going to worsen our patient care, but it’s going to improve their bottom line,” Mukkamala said. “And that’s the wrong calculus to use to improve health care in this country.”Momentum for automatic downcoding comes as experts say an inverse problem of “upcoding” is on the rise. Upcoding is when patients and plans are billed as though a higher level of service occurred, like when a bill is sent as though you had an appointment with the doctor, but you only ever saw a nurse practitioner. In 2021, the Centers for Medicare and Medicaid Services called upcoding “a serious problem” and the federal government periodically brings improper billing cases, both criminally and civilly, against health care providers.But the AMA position is that automatic downcoding — as opposed to insurers reimbursing for a lower level of service after reviewing additional information from physicians — doesn’t have any clinical logic behind it. For instance, when you visit a...