Insurance Down-coding: Blue Cross Blue Shield of TN (BCBS TN)
BCBSTN notes on their website that,
“Tennessee is home sweet home to you, your patients and us. We’re a mission-driven, not-for-profit focused on helping you serve BlueCross members,” but don’t be fooled. According to Tax returns on Pro-Publica BCBS of TN listed assets of $1,126,787,082 Billion, and 2023 revenues exceeding $800,000,000 but they are still squeezing healthcare providers in TN for more money.
Presently, BCBS of TN has enacted a process of down-coding healthcare claims which they announced in a March letter (below) to all contracted healthcare clinicians. They call it “Over-Coding” which implies codes are purposefully over-coded from what they should be, when the reality is the BCBS of TN is unilaterally downcoding claims without a fair process to healthcare clinicians and psychiatrists.
Down-coding means that if a doctor, nurse practitioner, or therapist uses a more expensive CPT code appropriately, that it will be automatically changed to a lower code and payment will be reduced lower regardless of what actually happened in the visit. Despite legitimate high acuity of the patient care, a larger amount of time spent with the patient, or the additional time needed by the healthcare clinician to communicate on behalf of the patient situation, down-coding occurs.
Insurance Downcoding is a contractural violation by healthcare insurance companies but the process is not currently illegal in Tennessee. The American Medical Association developed CPT codes and has guidelines for how insurance companies should use the codes and what they should do if they feel the physician is not using codes appropriately.
Downcoding is a contractural violation. Physicians sign a contract with insurance companies. Doctors provide the service and insurance companies pay. There is a process if the insurance company doesn’t believe the claim, they request records. Short of this process, an insurance company is violating a contractural agreement.
Downcoding hurts patients and healthcare clinicians. Down-coding provides inaccurate information and delays the billing process causing confusion for patients and physicians. The process degrades trust between patients and healthcare clinicians, between patients and insurance companies, and between clinicians and insurance companies.
Downcoding delays payments for work completed. Because downcoding delays accurate payment for work completed, insurance companies hold onto additional monies (50-100% or more per code changed depending on what was downcoded). In Tennessee this could be a violation of the TN Prompt Payment law, and clinicians that are victims of BCBS holding money could be entitled to interest on payments due. The problem is that the interest that has to be paid to the doctor, is less than what the insurance company is going collect by delaying payment. WE need insurance company reform.
Downcoding is a mental health parity violation. As of Jan 1, 2025, all health care insurance companies are being held to pay mental health clinicians like every other healthcare clinician. Which means mental health clinicians got paid like every other clinicians. Psychiatric offices spend more time with patients because they need to to keep patients out of the hospital. Psychiatric offices see sicker patients, because they are mental health specialists. When BCBS of TN down-codes psychiatric offices to lower codes than other healthcare offices, this, in effect, is unilaterally paying less for mental health care than other medical care.
Downcoding will reduce patient access to care. This downcoding process implemented currently by BCBS of TN, but clearly perpetrated by other payers in the past, will just hurt access to care. Psychiatric offices are small. Those that accept insurance are even more limited. TPA is advocating for more physicians and mental health offices to go in-network, but if payers don’t pay their bills or delay payment, offices can’t pay their bottom lines and will leave their contracts which which will reduce the number of in-network practices (which may be the insurance company tactic long term).
The Resolution? TPA is in talks with the TN Medical Association and other Medical Societies in TN to consider legislation to fix this problem. TMA has talked to BCBS (see below for a summary of conversations and ideas to help based on BCBS of TN responses to TMA). Many other insurance companies have tried down-coding with the single objective to save money, and ultimately abandoned in the past (see references below). The only known benefit to these schemes is for the insurance company to retain money and pay health care clinicians less which is ultimately why they engage in this process.
How you can help? Whether you are in-network or filing out-of-network claims, file immediately for reconsideration for all down-coded claims to BCBS of TN. Don’t terminate your contract with the payer, even if you are frustrated.
Send chart records (with patient consent) to justify your billing or attach information to support the level of E & M coding that was filed originally; make sure your diagnoses severity is appropriate with CPT codes used.
Call and Email your BCBS of TN representative explain your care to patients.
Call and Email BCBS of TN Management Teams.
Call and Email the TN Insurance Commissioner’s office and report the issue.
If you are a TMA member, report the problem. Join the insurance committee to help resolve the situation. If you are not, join the TMA, they are more powerful than TPA and can help.
Consider writing an editorial, blog or similar emphasizing the effects on patients, payers, and the processes, and the ultimate effect on access to care.
Hang in there and know that TPA is trying to help!
Remember you are advocating for your psychiatric patients and your completed work on their behalf.
References:
BCBS of TN notice about E&M downcoding process (they call it Overcoding)