NC Health Insurance Payers to Downcode with Claims Review Programs
The NCMS recognizes several health insurance companies have recently implemented claims and code review programs resulting in the down coding of certain Level 4 and 5 Evaluation and Management (E/M) claims.
This UM tactic scrutinizes Level 4 and 5 E/M claims for “correct coding” and performs pre-payment edits as payers deem appropriate, ultimately resulting in claims being paid at a lower rate than originally billed. As claims review programs are being defined by their policy guidelines, there is no separate notification when claims are downcoded, so practices are strongly advised to monitor remittance of documents for appropriate payments. Inclusion in such claims review programs generally lasts for one year; however, practices can pursue early removal from the program by successfully appealing 75% of down-coded claims. We encourage you to contact payers for additional information about these programs should you find yourself involuntarily participating.
The AMA has actively addressed this issue over the past year, collaborating with specific payers to tackle concerns. In partnership with state medical associations and specialty societies, the AMA crafted model legislation to support state initiatives aimed at reducing automatic downcoding.
The NCMS has directly engaged with certain payers, highlighting the significantly negative impact of their downcoding practices on physician practices in our state.
Jenni Hines, Manager of Payer & Practice Engagement, maintains close relationships with payers, and is dedicated to helping facilitate solutions for your practice. You can reach her at [email protected]. NCMS remains committed to resolving this issue through non-legislative means and will continue fostering open communication with payers to seek lasting solutions.
To help avoid inclusion in these claims review programs and ensure appropriate payments from payers, always verify benefits before each visit, as coverage and policies may change. Additionally, providers need to code and bill the highest level of specificity for diagnoses and ensure proper documentation within the medical record.
To help ensure proper claim processing, providers should:
- Stay current on coding changes, payer policies and relevant regulations to ensure compliance
- Maintain thorough and accurate medical documentation to support billed services and accurate coding
- Ensure medical necessity is met for the visit and supports the services rendered
- Appeal downcoded claims when documentation supports a higher level of service