Independent practice physicians in Dallas say that algorithms being used by commercial payers Aetna and Cigna are slashing payments by downcoding certain procedures, DMagazine reported Oct. 21.
One practice owner characterized the downcoding policy as “guilty until proven innocent.” Practice administrators said that while reviewing billing statements, they began to notice that patients who were coded as complex were being downgraded to a lower acuity and lower reimbursement rate.
Physicians in the Dallas area told the publication that Aetna has been “automatically downcoding their patient interactions without notice or explanation,” possibly creating a significant financial loss.
“We don’t even know upon what basis they are downcoding,” one physician told the publication anonymously out of fear of retaliation from the insurance company. While it is common for payers to not provide explanation as to why a procedure is coded a certain way, sources told DMagazine that before the new policies were in place the insurer would contact the practice to request more information about specific codes. But in recent months, the downcoding has taken place automatically, requiring practices — often resource-strapped — to carefully review billing records and identify changes.
Physicians told the publication that this practice has been taking place for several months, and that they received a notice from Cigna in the summer that the insurer would be implementing a similar policy in October.
In a document obtained by DMagazine, the policy reads: “Cigna has developed a new reimbursement policy. Cigna may adjust the E/M CPT code 99204-99205, 99214-99215, 99244-99245 to a single level lower when the encounter criteria on the claim does not support the higher-level E/M CPT code reported.”
While it has long been required that physicians justify the care given to a patient, they said that the new policy is frustrating due to the lack of notice regarding when a procedure has been downcoded. One practice calculated that it would have to hire an additional full-time employee to review and appeal the Aetna automatic downcoding. Instead, practice managers said that they opted to leave Aetna’s network, leaving hundreds of patients out of network.
“We can’t keep dropping insurance for the same reasons,” another physician told DMagazine. “There’s going to be a point where we have to make a serious choice about who we want to be as a practice and what sort of patients we want to serve. These insurance companies are going to choke us to the point where we can’t afford to keep up with their documentation requirements.”
Physician advocates have begun pushing back. DMagazine obtained a letter the Texas Medical Association recently wrote to Cigna, urging the insurer to immediately rescind the policy. The letter goes on to assert that if the documentation does not justify the code, the insurer should clearly notify the practice that the service was downcoded.
Aetna and Cigna did not respond to DMagazine’s request for comment on the story. But insurers have previously stated that such policies are implemented to reduce fraud and ensure consistency in claims processing, according to the report.
