Timely and fair payment is what the healthcare providers look for. Downcoding is a threat to this. Insurance companies down code the claims to save money. The payers feel it takes time for analyzing if the services are accurately performed. At times, the level of service for some diagnostic codes does not match the E&M codes. The payers have started to downcode these claims, and lowered the reimbursement for them. This happens after further reviewing, and you can never expect the claims to be paid right after flagging. On the other hand, healthcare providers feel that Downcoding is done by the payers simply to pay less and save money.
Documentation does wonders:
What can you do to prevent this? Simple, you need to concentrate on the claims from the very beginning. The documentation process has to be neat, and done meticulously. Necessary documentation justifying the E&M service prevents downcoding or denial. Systematic documentation is the key to the claim getting paid right. If the level of service is missing from the patient record, it would simply mean that it was not done. If there is a check-off sheet to fill during the visit, this error can be cut off. However, never make it complicated. This one has to be easy. Creating a template can serve this purpose. This also additionally keeps the doctor reminded about the E&M service level to be recorded.
Get help from the coders and billers:
Always keep in touch with the coders. Let them come back to you, when they feel some codes are to be changed, and when they feel something goes missing. For this, the coders and billers should be efficient enough to identify the mistakes and should have an eye for detail. In case of suggested changes, sending a memo by a coder simplifies the process. Even before the payer plays his role, the job is finished. If a copy of the coding section is also attached with the memo, things are pretty easier to track for the physician. Coders and billers discussing with each other helps to rectify the errors before submitting the claims.
Track the pattern:
Tracking the pattern of denials and downcoding is another strategy. Coders and billers need to track the reasons of downcoding and denials. If a few codes of services are denied persistently, then it is the place to sort things out. For instance, if patient information is not accurate, or the claim numbers are not right, or the identification numbers going wrong, or something else, is repeatedly seen as the reason for rejection, then it helps you cut the problem off. When you see no reason, and the payer is downcoding for no good reason, then it is time to contact the payer regarding the same.
You are not alone in the case of downcoded claims and lesser reimbursements. A few groups like local and state medical societies, hospital-physician organizations are into active fight against unfair downcoding. You can also join them and ensure your claims are fairly paid.