Prevent downcoding by insurance companies on medical claims

Have you ever wondered why sometimes the insurance company has “changed the code to a more suitable code for payment” when you get reimbursed for a claim? You submitted the claim as a 99214, but they paid you for a 99213 or worse, a 99212. This practice is called downcoding.

Should you accept it? In some cases, yes. Much will depend on the contract you have with the insurer. Some contracts only allow providers to charge certain CPT codes. In that case, they can change a billed code to one of the allowed codes. Or the contract may specify that you can only bill a certain number or percentage of claims at the higher codes.

But sometimes an insurance company will just downcode your claim and it’s not due to contract specifications. In that case you can object. We recently had a claim that the insurance company downcoded a 99214 to a 99213 and told us that they only allow a provider to bill a 99214 to a patient every 6 weeks. That is ridiculous. How can that guideline apply to every patient?

Sometimes we have to remind the insurance companies that the doctors are the ones who determine the needs of the patient. In this case, we sent office notes and a letter informing them that we objected to the handling of the claim. The doctor had met the requirements to justify the bill of a 99214 and their “guidelines” were inappropriate. We received payment for the difference about 10 days later.

So if you’re having trouble downcoding your claims and they’re not due to contract specs, you should object. Don’t just accept what the insurance company does. They count on that. Just think of how much money they save on the providers that don’t do anything about it.

Copyright 2008 – Michele Redmond

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