Cigna will roll out a policy that tracks how physicians bill. It will flag those who submit a higher proportion of level 4 or level 5

[biglurker]

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An insurance company is introducing a new threat to American medicine

Prior authorizations were once a narrow tool to contain costs. Downcoding could be next.

www.statnews.com

"Insurance companies continue to innovate.
On Oct. 1, Cigna will roll out a policy that tracks how physicians bill. It will flag those who submit a higher proportion of level four or level five visits — which get reimbursed at a higher rate — than their peers. For doctors placed under this extra scrutiny, certain claims at those higher levels may be adjusted down by one level if the billing details do not appear to justify the service. The affected codes include 99204–99205 (new patient, office/outpatient), 99214–99215 (established patient, office/outpatient), and 99244–99245 (consultations).

Cigna says the goal is to fight upcoding and billing abuse, arguing that some physicians bill for more complex visits than were actually provided, such as charging for a 40-minute encounter when the visit lasted only 10 minutes, and that these patterns drive unnecessary costs for patients and employers."

 

[HemeOncHopeful19]

This has been going on for at least 10-15 years though?

 

[DrMetal]

If a physician is documenting correctly (throwing in 'complexity' blurbs), there's no way you can stop them from billing higher. I can make a paper cut look like the most complex thing, on paper (pun intended).

So Cigna's strategy here is unlikely to work (in achieving cost savings).

Unfortunately, what does that mean? When they realize they can't stop doctors from upcoding, they'll just decide to reimburse less.

 

[HemeOncHopeful19]

If a physician is documenting correctly (throwing in 'complexity' blurbs), there's no way you can stop them from billing higher. I can make a paper cut look like the most complex thing, on paper (pun intended).

So Cigna's strategy here is unlikely to work (in achieving cost savings).

Unfortunately, what does that mean? When they realize they can't stop doctors from upcoding, they'll just decide to reimburse less.

I do think there are some docs that don’t document correctly to be fair - but this isn’t anything new

 

[DrMetal]

I do think there are some docs that don’t document correctly to be fair - but this isn’t anything new

Sure, they deserve to be down-coded.

But then how will they react? They'll find out exactly what documentation is necessary (in order to achieve the maximum complexity), then they'll create blurbs, templates, dot-phrases, throw in some AI . . . to achieve all of this. (this is why our notes have become so riddled with crap and illegible)

Cigna knows this, they ain't stupid. This is just their first attempt, to make it look like they tried something else (asking doctors to down-code them selves) . . . then they'll just reduce reimbursement rates (which is what they've intended to do all along).

 

[bronx43]

If a physician is documenting correctly (throwing in 'complexity' blurbs), there's no way you can stop them from billing higher. I can make a paper cut look like the most complex thing, on paper (pun intended).

So Cigna's strategy here is unlikely to work (in achieving cost savings).

Unfortunately, what does that mean? When they realize they can't stop doctors from upcoding, they'll just decide to reimburse less.

Not really true in the outpatient setting, where most of this is targeted. Coding in clinic is based on risk, which has relatively strict criteria. You can't make a low risk problem like contact dermatitis into a level 5, no matter how hard you tried.

 

[chessknt]

If a physician is documenting correctly (throwing in 'complexity' blurbs), there's no way you can stop them from billing higher. I can make a paper cut look like the most complex thing, on paper (pun intended).

So Cigna's strategy here is unlikely to work (in achieving cost savings).

Unfortunately, what does that mean? When they realize they can't stop doctors from upcoding, they'll just decide to reimburse less.

I mean it will work--it will cost them almost nothing to just automatically downcode everything that doesnt meet their imaginary guidelines. You then have to waste time appealing to get paid correctly. Only way to fight this is with AI automatically appealing their automatic downcodes, using up more resources. Everything will get more expensive. This should be illegal but our current political leadership won't be doing jack **** to stop this.

 

[chessknt]

Not really true in the outpatient setting, where most of this is targeted. Coding in clinic is based on risk, which has relatively strict criteria. You can't make a low risk problem like contact dermatitis into a level 5, no matter how hard you tried.

How is it strict? Is there a list of approved high risk conditions somewhere I havent seen? It is based on a subjective assessment of 'severe' exacerbation or 'high risk' of life/organ threat.

 

[HemeOncHopeful19]

How is it strict? Is there a list of approved high risk conditions somewhere I havent seen? It is based on a subjective assessment of 'severe' exacerbation or 'high risk' of life/organ threat.

I think it is hard to claim you are considering major surgery or high risk therapeutics requiring intensive monitoring for a papercut...

 

[chessknt]

I think it is hard to claim you are considering major surgery or high risk therapeutics requiring intensive monitoring for a papercut...

Ok what if the papercut is infected locally? What if there is evidence of an ascending infection? Do they have to be septic to qualify or just have an alarming exam? Where is the line? There isn't one--it is subjective.

 

[HemeOncHopeful19]

Ok what if the papercut is infected locally? What if there is evidence of an ascending infection? Do they have to be septic to qualify or just have an alarming exam? Where is the line? There isn't one--it is subjective.

Well to bill a 99215 you need 2 of 3 of the following

- threat to life / bodily function (I think you could fudge this)
- discussion with external physician OR independent interpretation of a test performed by another provider (hard to fudge this for a papercut IMO)
- drug therapy requiring intensive monitoring OR consideration of major surgery OR decision regarding hospitalization (hard to fudge this IMO although I suppose you could claim you "considered hospitalization" for this papercut... I think that might not stand up to audit)

 

[chessknt]

Well to bill a 99215 you need 2 of 3 of the following

- threat to life / bodily function (I think you could fudge this)
- discussion with external physician OR independent interpretation of a test performed by another provider (hard to fudge this for a papercut IMO)
- drug therapy requiring intensive monitoring OR consideration of major surgery OR decision regarding hospitalization (hard to fudge this IMO although I suppose you could claim you "considered hospitalization" for this papercut... I think that might not stand up to audit)

Exactly--lots of grey zone which is why any kind of automated downcoding happening will be pure malicious greed by the insurance companies. If they are concerned they should invest their resources in to auditing people outside of their norms to see if they are actually upcoding or, more likely, just seeing sicker people instead of globally applying this nonsense but of course it was never about controlling costs, just increasing their profits and making healthcare worse.