A Connecticut doctor is claiming he’s the victim of repeated under-reimbursements by insurance companies, a practice called “downcoding” that he said cost him close to $100,000.
“This is insane,” said Dr. Peter Hahn, a cardiologist and vein specialist in Uncasville. “The amount of time and extra work I have to do to get paid appropriately, it is crazy, and it's theft.”
Hahn’s fight centers on an obscure health-industry practice called “downcoding,” which will be part of a state public hearing on March 3.
Downcoding occurs when an insurer reduces a billing code submitted by a provider. That results in a lower payment to the doctor. It’s a practice insurers say helps to combat improper billing and reign in ballooning health care costs.
But providers, and some state lawmakers, take a different view – calling downcoding a burdensome overreach by insurance companies that delays payments, saddles doctors with paperwork and undermines patient care.
Providers are “not going to be able to bill for a high-level visit and get paid for it,” Hahn said. “So why are they going to do it? The insurance companies, they hold all the cards here.”
Months of paperwork
Disagreements over billing codes submitted by a doctor can be appealed by providers, insurers say.
But health care providers argue those appeals can take months. What’s more, they say, is that an initial downcoding decision is often enacted by an insurer without a proper review of medical records.
“They can't just say, in advance, we're not going to pay you, and you have to then prove to us by writing the appeal letter,” Hahn said.
“This can take six months after the office visit, and then they have another six months to review it,” he said. “I could wait 12 months to get paid, and then oftentimes, like in my case, they just say, ‘No, it's too late. You're out of the timely–filing appeal window.’”
Hahn said he was currently engaged in a back and forth with Anthem.
“It's just this grueling slog of trying to write these hundreds of appeal letters; I’m having to pay a billing company to do all this,” Hahn said. “And then I have to review all the letters that go out, it’s a nightmare of time.”
In a statement, Anthem said health care fraud and improper billing drive tens of billions of dollars in costs each year, raising insurance premiums for policy holders and costs for employers.
“We take seriously our responsibility to ensure claims are coded correctly and providers are reimbursed appropriately,” Anthem stated. “Providers can dispute reimbursement decisions through an appeals process with supporting medical documentation.”
Legislative action considered
Connecticut lawmakers are considering several bills to reform downcoding this legislative session.
“We have seen too many health systems unilaterally downcode to delay and deny care and many people being hurt,” said state Sen. Jorge Cabrera (D-Ansonia) at the state Capitol.
It’s an idea that has the support of the Connecticut Hospital Association (CHA), an industry group representing hospitals and medical professionals statewide.
“Unequivocally, providers are not committing fraud in billing insurance companies,” said Paul Kidwell, senior vice president of policy at CHA.
The association educates doctors on billing codes and providers do not, as a rule, bill more for their work, he said.
His colleague Mark Schaefer, vice president at CHA, referred to downcoding as a "burdensome" practice driven by insurer algorithms, rather than patient medical records and clinical judgment.
“[It] undermines care, shifts costs onto patients and employers, and forces hospitals into costly appeals,” he said in a statement.
Ahead of the March 3 legislative hearing before the Insurance and Real Estate Committee, physicians submitted written testimonies in support of reforming the practice.
Dr. Ray Lorenzoni III, president of the Fairfield County Medical Association, drew an analogy to an auto repair shop in calling for better regulations.
“It would be as if an insurance executive waltzed into their auto mechanic shop, demanded his car be inspected, reviewed all the indicated repair options and prices, and agreed to the brake pads, rotors, fluids, tires, balancing, and alignment, but then insisted on only paying the shop for replacing the fluids,” he wrote. “How can you run a business like that?”
