downcoding

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

downcoding

(doun´kō´ding),
n a practice of third-party payers in which the benefits code has been changed to a less complex or lower cost procedure than was reported.
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References in periodicals archive ?
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.
Audits can now be performed on a weekly basis to catch downcoding or upcoding as it's happening," said David Byrd, Vice President of Sales and Marketing.
3) A study from the Department of Emergency Medicine at Maine Medical Center in Portland found that the use of pocket-sized dictation templates along with Continuous Quality Improvement methodology not only increased compliance with guidelines but also decreased the downcoding of charts and increased billable records.
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.
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.
We're looking forward to reducing downcoding and avoiding lost revenues, and we no longer have to photocopy the patient record for a billing clerk who needs to interpret our notations and create a bill.
Aside from this report, however, there is a lack of published research on upcoding or downcoding of the MDS.
For too many years, physicians have battled with insurers over significant business practices, such as one-sided contracts, determination of medically necessary services, and denying or downcoding claims," said Dr.