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Several large health insurers are drawing provider backlash for relatively new payment policies that reduce certain reimbursements. Cigna is automatically downcoding 6 evaluation and management (E/M) billing codes (99204- 99205, 99214-99215, 99244-99245) for a small percentage of providers starting this month, for example, resulting in lower payments for some routine office visits. The insurers are leveraging algorithms and claims data to automatically downgrade the codes—often relying on third party vendors to do the adjustments. According to NBC, Aetna, Anthem Blue Cross and Blue Shield, Humana, and Molina Healthcare also have been downcoding higher-level claims for certain office visits. Collectively, the insurers say that the downcoding is a method to root out fraud from outliers, affecting only a small percentage of providers, about 1-3%. From their perspective, the providers believe the insurers’ downcoding policies will lead to unfair underpayment. To reconcile, the providers would have to appeal the disputed claims individually with documentation, leading to increased administrative costs—and possibly a net loss on the appealed claims when all is said and done. Observers believe that the proactive payer denials are designed to presume providers are “guilty” of upcoding until proven “innocent.”
What to consider: If an urgent care center is flagged as an outlier, a significant portion of their routine claims may be automatically downcoded, directly reducing total revenue per visit. At the same time, an urgent care would need more staff time and resources to appeal underpayments without a guarantee of success, effectively reducing the net profit per claim even further. What’s more, the policy may create a financial disincentive for urgent cares to bill for bona fide complex patient visits, potentially leading to inaccurate billing and documentation practices adjusted to meet the insurer’s demands, rather than clinical integrity.