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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Whereas, down coding occurs when health insurance companies reduce the reimbursement level of a claim
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by changing the procedure code submitted by a physician, often resulting in lower payments for services
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rendered; and
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Whereas, health insurance companies often down code claims automatically without notifying physicians,
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making it difficult for physicians to track which claims have been altered; and
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Whereas, physicians are frequently required to submit additional paper documentation to appeal downcoded
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claims, creating unnecessary administrative burdens and delays in payment for services provided; and
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Whereas, automatic down coding without notification or justification limits the transparency and
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accountability of health insurance companies, negatively impacting physician practices and patient care; and
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Whereas, the appeals process for down coded claims is often cumbersome, time-consuming, and inefficient,
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placing significant strain on physicians’ administrative resources; and
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Whereas, fair and transparent claims processing is essential to maintaining a balanced healthcare system that
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compensates physicians adequately for their services; therefore be it
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RESOLVED, that MedChi work legislatively and/or regulatorily to prevent health insurance companies
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from automatically down coding claims without notifying physicians at the time the down coding occurs and
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providing a clear rationale for the adjustment; and be it further
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RESOLVED, that MedChi work legislatively and/or regulatorily to require that health insurance companies
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accept electronic documentation for appeals of down coded claims, rather than mandating paper submission,
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to reduce the administrative burden on physician practices and expedite the resolution of appeals; and be it further
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RESOLVED, that MedChi seek and/or support stronger regulatory oversight to ensure that health insurance
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companies provide timely notification and justification when a claim is down coded, and that physicians are
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given a fair and reasonable opportunity to appeal the decision electronically with appropriate supporting
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documentation.