Downcoding, delayed payments a 'revenue grab' by insurers, physician says

U.S. physicians routinely are seeing their higher-cost claims downcoded by insurers, a strategy a family physician in Cincinnati called a revenue grab, according to Medscape

Will Sawyer, MD, said that the downcoding has resulted in a significant decrease in reimbursement for his small practice. For example, he said when his office submits a claim with the code for a 30-39 minute office visit with moderate medical decision-making, Anthem often changes it to the code for an office visit of 20-29 minutes with low medical decision-making.

The downcoding results in $18 less for a complex visit, he said. In some instances, his office has resubmitted the claim with a copy of the encounter form for higher reimbursement, but the payment was still not changed.

"Anthem has been downcoding relentlessly since October 2020," Dr. Sawyer told Medscape

Anthem told Medscape it uses "analytical tools to review evaluation and management codes during the claims adjudication and processing process" and that physicians can dispute downcoding decisions by providing a statement explaining why they disagree and documentation to support it.

Dr. Sawyer also said that many insurers have been delaying payments amid the COVID-19 pandemic. This follows a Kaiser Health News report that found UnitedHealthcare and Anthem are behind on billions of dollars of payments to hospitals due to new reimbursement rules, claims issues and retroactive claims denials.

Kaiser Health News reported that Anthem is delaying payments through new paperwork, requirements for prior authorization or requests to speak with physicians directly, according to the report. Anthem said many of these steps are taken to control excessive prices from hospitals. 

Dr. Sawyer said he believes the downcoding and payment delays are ways for insurers to increase profits.

"When practices are running at warp speed, trying to keep people healthy and getting burned out, they aren't paying as close attention to the details of payment. It's an absolute revenue-grab strategy that's unconscionable," Dr. Sawyer told Medscape.

He also said he thinks other insurers, like UnitedHealthcare and Humana, are profiting from these strategies. 

"If they downcode millions of claims, a certain number of physicians will give up without appealing, and they'll raise their profits," Dr. Sawyer said. 

"We pay claims appropriately under members' plans and within the required time frame," a UnitedHealthcare spokesperson told Medscape

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