Insurance Companies Downcoding Your Claims

Ever wonder why sometimes when you get reimbursed for a claim, the insurance company has ‘changed the code to a more appropriate code for payment’? You submitted the claim as a 99214 but they paid you for a 99213 or even worse, a 99212. This practice is called downcoding.

Do you have to accept it? Well in some cases you do. A lot will depend on the contract that you have with the insurance carrier. Some contracts will only allow providers to bill 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 carrier will just downcode your claim and it is not due to contract specifications. In that case you can appeal it. We recently had a claim that the insurance carrier downcoded a 99214 to a 99213 and told us that they only allow a provider to bill a 99214 every 6 weeks for a patient. That is ludicrous. How can that guideline apply to any patient?

Sometimes we just have to remind the insurance carriers that the doctors are the ones who determine the patient’s needs. In this case we sent in office notes and a letter advising them that we were appealing the processing of the claim. The doctor had met the requirements to justify the billing of a 99214 and their ‘guidelines’ were inappropriate. We received payment for the difference about 10 days later.

So if you are having problems with your claims being downcoded, and they are not due to contract specifications, you should appeal. Don’t just accept what the insurance carrier does. That is what they are counting on. Just think of how much money they save on the providers that don’t do anything about it.