Ask MGMA: How AI is Driving Payer Downcoding and What Medical Practices Can Do About It
Download MP3Well, hi, everyone. Welcome back to the MGMA Ask an Advisor Podcast. I'm Daniel Williams.
Cristy Good:And I'm Kristi Good. Thanks for tuning in.
Daniel Williams:Yeah, today we are tackling a hot topic in the medical practice world, payer downcoding, especially the increase in downcoding driven by automation and AI. If you're seeing more of your claims being reduced without any review of your medical records, you're not alone.
Cristy Good:Absolutely, Daniel. We've been hearing from MGMA members across the country about this. So, today, we're going to walk through what's happening, why it's such a concern, and what practices can do about it. We've got about eight key questions lined up. So, let's go for it.
Daniel Williams:All right. First question, Christy, what exactly is payer downcoding and why are we seeing such a rise in it right now?
Cristy Good:So downcoding happens when a payer lowers the level of an E and M or evaluation and management code on a claim. So say you have a 99,214 and they downcode it to 99,213, reducing reimbursement. What's new is that many payers are using automated claims editing algorithms now with AI powered by AI. And this is doing this sometimes without actually reviewing actually is doing this without actually reviewing the medical records. This goes against the CMS guidelines, which require coding to be based on either medical decision making or total time.
Cristy Good:So it's not just frustrating, but it's also noncompliant.
Daniel Williams:All right. Thanks for that one. So number two, how are these AI based systems actually deciding which codes to down code?
Cristy Good:They're using historical data, things like patient demographics, common diagnosis codes, and frequency of high level billing. So if a claim doesn't match what the algorithm thinks is typical, it gets flagged. The problem, it doesn't account for the real complexity of the patient encounter. So if your providers are seeing complex patients or spending more time coordinating care, the AI might still down code based on averages.
Daniel Williams:Okay. Okay. And I'm still getting my head around this because this was actually new information for me, so I'm so glad you're explaining it to Let's just go to the next part of this. And why is this problematic for providers beyond just losing revenue?
Cristy Good:It's a huge administrative burden. So your staff not only is trying to catch those that are being downcoded, but they also gather the supporting documentation and they have to submit appeals. So they're already doing the front end work quite often with using their coders to code and document and making sure everything's in the right order and the right documentation, and they send it off. But if it comes back, it they may have to submit appeals, which is such an administrative burden on the practice. It also undermines the trust in the process.
Cristy Good:CMS and the AMA have both made it clear that claims should not be adjusted without review of medical records. So this kind of downcoding can lead to burnout, delay in payment, and even inaccurate performance profiles for providers.
Daniel Williams:Okay. That's blowing my mind because we keep thinking AI is just making things easier, but in this case, it's actually creating more administrative burden?
Cristy Good:Because of what the practice has to do to all to appeal, even if the practice is using some AI for help with their coding to make sure it goes over correctly to the billing. They're still getting a lot of denials, and then all those appeals are just another layer, and it's taken an employee's time to go through, gather again documentation, fill out the paperwork, and then resubmit those claims.
Daniel Williams:Okay. So.
Cristy Good:Making it easier on the payer.
Daniel Williams:Yeah. Yeah.
Cristy Good:But not the provider.
Daniel Williams:And that's not what we want here. We want to help our practices out there. So, if you are a practice suffering from this or you want to know if it's an issue for you, what are the signs a practice should be looking for to know if they're being down coded?
Cristy Good:I think probably many are checking their remittance advance. Phrases like service level adjusted based on payer policy or billed service inconsistent with diagnosis are common signs. Also look for patterns like high level E and M codes routinely paid as lower levels, especially by the same payer. If one or two providers seem to be impacted more than others, that's worth tracking as well.
Daniel Williams:Okay. Next up, what steps then should a practice take once they identify downcoding?
Cristy Good:They should check everything. Which payer, which codes, which providers, how many were appealed, and how long it took, and how many were overturned. Appeal every unjustified downcode with supporting documentation, and send that data both to the AMA and even to our MGMA government affairs team here, which would be gov, G0VAFF,@MGMA.com, because they're gonna be looking at how many practices are being impacted by this downcoding, and those examples will help us advocate for better payer accountability.
Daniel Williams:Okay. Do we know right now at all how widespread this is? Is it across all practices?
Cristy Good:Well, I'm getting, it's a number of Blue Cross Blue Shields. And I am getting, we know that UnitedHealthcare had a big thing about it, about using AI to look at their claims. I know that our government affairs said they are working with a couple practices already, and we just seem to be getting more and more questions coming through to us saying, I'm doing all that I should be doing. I need help. They're still denying.
Cristy Good:And now it's causing me more work on our end to reappill those.
Daniel Williams:Okay. Let's talk documentation then. What can practices do to reduce their risk of down coding in the first place?
Cristy Good:So we know that good documentation is your best defense. So be specific, clearly outline your medical decision making process, document total time if time based coding is used, and make sure to include any chronic conditions or comorbidities that impact the visit. Avoid copy paste template language. That is a big thing that I think causes some of this to happen with and gives red flags to the AI system. If you're not already doing annual external audits, that is something I'd recommend.
Cristy Good:And, of course, your internal audits. If you're having certain providers that seem to be more affected than others, definitely get those audited because there could be some documentation. You might be thinking you're doing it right. The providers might be thinking they're doing it right, and there might be something that's being missed.
Daniel Williams:Okay. Now you raised something here that, again, it just, it caught my attention. You said avoid copy paste template language. It raises red flags there. Tell me what that is.
Daniel Williams:I can imagine what it is, but I'm not really sure in a practice what's happening so we can certainly try to provide insight for our listeners so they don't do this.
Cristy Good:Yeah, it's in the EHR. When you're just copying your note from your previous note, or you're using the same templates over and over as your diagnosis, you, because you can build templates in your EHR, but if you're constantly using certain templates for all your patients with diagnosis and reasoning, that it does make it look like possibly you haven't looked into that patient as deeply as maybe you should, or you're missing something, it's just another little red flag. So even when I did some EHR implementations, we built those templates, but we also reminded them not to just copy and paste previous notes and not just to use specific templates for everything.
Daniel Williams:Okay. All right. Thanks for sharing that information. Let's talk about what role AI can play on the provider side then. Can practices use it to their advantage?
Daniel Williams:Because you and I have talked many times about AI as a tool, something we can work with to help us do things more efficiently, etcetera. But I'm hearing bad news for AI right here. So how do we use it to our advantage here?
Cristy Good:No, absolutely. And that's what I've even told our members, that you combat their AI with your AI. You just make sure that if you're using AI driven coding assistance or audit tools to assess your claims before you submit it, just also take a look and make sure that it's doing what it should be doing. These tools can flag missing documentation or inconsistent coding and then help ensure that your claim meets those payer expectations before they get rejected or down coded. It is a great way to level the playing field when we know payers are using AI driven tools too.
Cristy Good:But just like with any AI, it is machine learning, and you should always make sure you're checking what it's giving you, the answers it's giving you, what it's doing. And even if it's sending clean claims over, and you're getting denials, it's still worth looking into.
Daniel Williams:Okay, that makes sense. That makes total sense. So what can practices do from an advocacy or policy standpoint to push back? I know you mentioned earlier about AMA. You also talked about MGMA's government affairs teams.
Daniel Williams:I know I was on an email chain you shared with me where you were actually chatting with our government affairs team. So let's talk about that from that advocacy or policy standpoint.
Cristy Good:Sure. First, it's great to hear from our members out there that are experiencing this. I suggest posting your experience on the MGMA community. If you're not involved, it's a great way to get advice from your colleagues, chat with your colleagues, share thoughts with your colleagues. And it just helps us see if there's some trends across practices, because if more people are posting, then we'll be knowing that it's not one person affected, it's more.
Cristy Good:Second, report patterns to the AMA. I know the AMA has been looking at this, so I think they have a downcoding survey, and I think we we'll have a link to the article from the AMA on this at the end of our podcast. So in there is a survey link that you can go to. And then third, if you believe your payer is violating contract terms or state regulations, you can file a complaint with your state insurance department and then send us your data. We work with MGMA's, our government affairs team, and they're really pushing for transparency and fairness in payer practices.
Cristy Good:So the more they know, the more they can advocate for our members on behalf.
Daniel Williams:Okay, that sounds great. Because we've covered a lot of information, Christy, help us just, I guess the best thing is to, what are three big takeaways you'd want our listeners to know from this conversation today?
Cristy Good:Sure. The first one, be vigilant. Track everything and know your data. That is really key. You should know what's coming in, going out, doesn't make sense, and track it.
Cristy Good:Be proactive, strengthen your documentation, and appeal when needed. If you have questions on documentation, you can reach out to us here at askadvisormgma dot com or any of the other coding resources out there. And then be connected, use MGMA, use our community, and the AMA, and your state channels.
Daniel Williams:Perfect. And everybody, as Christy said, we're going to drop some direct links there in our episode show notes. And if you are looking for support with coding audits, compliance tools, or payer strategy, reach out to us at advisormgma dot com. You can also contact consultingmgma dot com if you're ready to bring in additional expert help.
Cristy Good:Thanks for spending time with us today, and we hope this gives you the tools and confidence you need to address your repair downcoding in your own practice.
Daniel Williams:Until next time, I'm Danielle Williams.
Cristy Good:And I'm Christy Good.
