The American Medical Association’s House of Delegates voted to strengthen medicine’s opposition to insurer downcoding practices that wrongly reduce payment for physician services and can threaten patient access to care.
Physician and medical student delegates approved the policy at the AMA’s Interim Meeting in Orlando, Fla., according to a Nov. 9 news release from the organization.
Under the new policy, the AMA will work with other physician organizations to strengthen advocacy against unilateral payer downcoding. The effort will also help physicians understand new legislative protections, report health plan noncompliance to regulators and challenge inappropriate payment reductions.
Delegates also directed the AMA to develop and regularly update educational resources to help physicians document services appropriately, appeal unjustified downcoding and report inappropriate payer conduct.
Downcoding programs can automatically lower the level of service a physician reports, sometimes through algorithms or other automated tools that skip review of the patient’s medical record. The AMA said the practice adds administrative and financial burdens for practices and undermines transparency in claims processing.
Physicians “should not have to fight insurers to be paid accurately,” AMA board member Michael Suk, MD, said in the release. Dr. Suk added that the AMA will keep pursuing legislative, regulatory and legal solutions that hold insurers accountable.
The AMA supports legislative guardrails that would prohibit automatic downcoding without clinical record review, require clear notice and explanations when claims are downcoded, and establish meaningful appeal processes.
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