Legislative Updates

Information Regarding Downcoding

POSTED IN: Insurance, Legislative Updates,

One of the issues that we’ve started to notice in Missouri is the automatic and arbitrary downcoding of charts. We find this to be a very important issue and are working on solutions. While we work on that, we’d also like to pass on some advice from Dr. Todd Taylor, an ACEP member and a national expert on billing and coding. He is discussing being audited by an insurance company but many of the same principles apply whether it is an audit or the company just downcoding the charts.

IMPORTANT: While the following is written in response to a specific incident (in process), EVERYONE should heed this advice and have a process in place for when you will eventually suffer the same fate. By the time you are hit with an audit, it may be too late to effectively figure out how to deal with it


In case it is not otherwise obvious, such audits must be addressed aggressively. While you may get some useful advice on this list, you should probably seek professional assistance and be prepared to go court. Such things have a way of snowballing. 


To follow are some salient points from my experience (on both sides) dealing with such things. 


This sort of “audit” is a common tactic and falls into the category I call, “stupid payment tricks”. How convenient for the payer to hire auditors, incentivize them to down code, be liberal with coding interpretation, look at only a subset of encounters, then apply that percentage to everything they ever paid you. Further, they will likely start to “withhold” future payments while this is being sorted out. Great way for them to create a (false) cash flow. 


From my experience on the auditing side, do not assume the auditors are even qualified, that their processes are valid, or there are no significant bias\conflict of interest. I was “asked not to continue” as a physician Medicare auditor for a large national RAC PRO because I disagreed with the initial nurse auditors conclusions too often and took too much time reviewing charts (i.e. I was not willing to just “take the word of the nurse reviewers” – who BTW were also under similar pressure to deny & review quickly). I was instructed to spend no more than 10 minutes per case, despite being required to sign a Medicare attestation that I had fully and completely reviewed the medical records. These were inpatient charts, often 100’s of pages. 


Salient Points:


#1 Do you have a contract with them? If so, you need to read it carefully. There should be some provision for grievance\appeal process &/or arbitration. You should also look at the contract termination clause. Most contracts run for 12 months and you may have to notify them up to 6 months in advance to terminate. Do not miss that window. The first thing I usually did when faced with this was to terminate the contract. That makes their ability to “withhold” & down code more difficult, because you can simply balance bill the individual patient and let the payer deal with their “angry customer”. 


#2 If they choose to start to withhold, you of course should challenge that and if necessary go to court to seek an injunction. Again, some of this may depend on what your contract says if you have one or state regs. 


#3 Request a list of all of the audited charts & state in no uncertain terms that you do not accept at “face value” their conclusions, nor do you accept their sampling methodology, nor the implication they can use the sample percentage as a basis to recoup payments on encounters that were not part of the audit. In other words, you intend to challenge each and every case, and the only way they can recoup payment is to prove a coding error on a case-by-case basis. Unless your contract says otherwise, you do not have to accept their recoupment method. Also, request a copy of their audit process, policy, and qualifications of their auditors. 


#4A Now the hard (expensive) part begins. Start with your billing\coding company. They have a vested interest in helping in this  fight. I attended the ACEP Reimbursement and Coding Conference (www.acep.org/rc/), learned how to determine the E/M coding level and reviewed charts myself. In fact, I did so on a routine basis as a QA\CQI process for both docs & billing company. I then presented the evidence using standard E/M coding criteria (which as noted is NOT based on diagnosis\disposition) for each and every case. Now, to be fair, I did occasionally find errors and there were some that were equivocal. So I would designate cases into three criteria: Confirmed\Equivocal\Error. The “error” group was typically less than 1-2% and overall 95%+ confirmed. I might then make an offer for settlement based on that 5%. If not accepted, then we head to arbitration (if required by contract) or a formal grievance\appeal process. Arizona has a great appeals process in this regard via the Dept of Insurance. As a result, most encounters (90%+) were eventually found in favor or the provider. In short order, payers simply stopped doing this because it cost them way more to fight the appeal than what they eventually get in recoupment. In other words, the coding\billing process works fairly efficiently as long as payers do not create false disputes. Regardless, you will need to quickly figure out what your appeal options are. These are typically time limited and may be a short as 30 days. 


#4B Hire someone to manage the entire process. This may cost you as much or more than you stand to lose (in the short term), but what you want to ultimately accomplish is to squelch these capricious activities. They will eventually leave you alone if you hold their feet to the fire. 


Bottom Line: At this juncture, you will likely need to hire an expert. You may not have time (or desire) to learn the process nor have the experience necessary. I eventually leaned (by the seat of my pants) how to manage these sorts of things, but that takes a while. Nevertheless, after losing my very first appeal, I never lost another one (including my own personal case). It takes dogged determination.