Prevention of Automatic Down Coding of Claims by Health Insurance Companies Without Physician Notification

MEDCHI, THE MARYLAND STATE MEDICAL SOCIETY

HOUSE OF DELEGATES

INTRODUCED BY: Montgomery County Medical Society

SUBJECT: Prevention of Automatic Down Coding of Claims by Health Insurance Companies Without Physician Notification

REFERRED TO:

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  1. Whereas, down coding occurs when health insurance companies reduce the reimbursement level of a claim

  2. by changing the procedure code submitted by a physician, often resulting in lower payments for services

  3. rendered; and

  4.  
  5. Whereas, health insurance companies often down code claims automatically without notifying physicians,

  6. making it difficult for physicians to track which claims have been altered; and

  7.  
  8. Whereas, physicians are frequently required to submit additional paper documentation to appeal downcoded

  9. claims, creating unnecessary administrative burdens and delays in payment for services provided; and

  10.  
  11. Whereas, automatic down coding without notification or justification limits the transparency and

  12. accountability of health insurance companies, negatively impacting physician practices and patient care; and

  13.  
  14. Whereas, the appeals process for down coded claims is often cumbersome, time-consuming, and inefficient,

  15. placing significant strain on physicians’ administrative resources; and

  16.  
  17. Whereas, fair and transparent claims processing is essential to maintaining a balanced healthcare system that

  18. compensates physicians adequately for their services; therefore be it

  19.  
  20. RESOLVED, that MedChi work legislatively and/or regulatorily to prevent health insurance companies

  21. from automatically down coding claims without notifying physicians at the time the down coding occurs and

  22. providing a clear rationale for the adjustment; and be it further

  23.  
  24. RESOLVED, that MedChi work legislatively and/or regulatorily to require that health insurance companies

  25. accept electronic documentation for appeals of down coded claims, rather than mandating paper submission,

  26. to reduce the administrative burden on physician practices and expedite the resolution of appeals; and be it further

  27.  
  28. RESOLVED, that MedChi seek and/or support stronger regulatory oversight to ensure that health insurance

  29. companies provide timely notification and justification when a claim is down coded, and that physicians are

  30. given a fair and reasonable opportunity to appeal the decision electronically with appropriate supporting

  31. documentation.