The alteration by an insurer or other third-party payer of service codes for physicians or other health care providers, to those of lesser complexity, resulting in decreased reimbursement
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The reviewers found that SNFs had included "upcoding" -- use of inaccurate, more expensive billing codes -- in 20 percent of the claims and downcoding in just 2.
if low-scoring providers are more likely to seek out low-risk patients) or downcoding (i.
In 2002, the NCMS sued in state court alleging that United's practices - improper coding, bundling, downcoding, edits, improper use of guidelines, and poor claims resolution - breached contracts with physicians (North Carolina Medical Society v.
Plaintiffs claim that the problem is not upcoding and unbundling by providers, hut rather is arbitrary and unjustified downcoding and bundling by bill-review companies.
Product: PrivaNotes EMR Captures encounter data, so documentation supports billing and reduces unnecessary downcoding.
They also claimed that making payments on a basis other than the medical necessity definition contained in their agreements with the insurers constituted a pattern of racketeering activity and that failing to pay their claims, or the downcoding of their claims according to a new standard other than medical necessity, was a breach of contract.
after the managed care organization began downcoding claims on outpatient office visits.
Marks said he's seeing more class action and individual suits by physicians seeking compensation that was denied due to downcoding, bundling, or other reasons.
Ample evidence of facility confusion has surfaced over the years, most particularly in the recent OIG study disclosing a mishmash of PPS upcoding and downcoding without apparent reason.
Suits that include claims for downcoding, bundling, and other forms of underpayment, nonpayment, and late payment have been asserting violations of the Racketeer Influenced, and Corrupt Organizations Act, fraud, misrepresentation, and--as used in the CIGNA case--breach of contract.