Downcoding: How payers are cutting payments and what family physicians can do

Welcome to Inside Family Medicine, where you hear from leaders and peers in your specialty while learning about new tools and resources. I'm your guest host, Karen Johnson, vice President of Practice Advancement for the AAFP. Today we are joined by AAFP member, Dr. Tina Philip, who owns Oakwood Family Medicine in Rock.

Round Rock, Texas and Shawn Martin, executive Vice President and CEO of the AAFP. Welcome Tina and Shawn and thank you both for joining us. Thanks, Curtis. I'm gonna Well, you're welcome. Yeah. And I'm gonna let each of you tell our listeners a bit more about yourselves when we delve into today's conversation, and we are here to talk about down coding.

A practice used by payers that has been on the rise and getting attention from a lot of folks, including the AAFP. The use of down coding is not new, but is increasingly in the news as more payers adopt this cost control strategy, creating payment and administrative burden issues for family physicians in their practices.

And before we delve into down coding Dr. Philip, I'd really like to start with you to tell our listeners a bit more about yourself, including your response to the opening question that we like to ask all of our family, physician guests, why did you choose family medicine? Well, thanks for having me again.

I'm Tina Philip. I am a solo independent family physician in Round Rock, Texas. I have been practicing medicine for 17 years, but I've been in private practice for myself for the last six. Why did I pick family medicine? That's a big question. Right? When I went into medical school, I did not have family medicine on the radar at all.

It was not actually my choice, but I was fortunate enough to do my third year medical student rotation at John Peter Smith Hospital in Fort Worth, Texas, and. Got to see the breadth of what family medicine physicians actually get to do. I, I don't think I really fully understood how much a family physician could do, and I really appreciate, you know, developing those relationships with my patients.

I have patients who've been seeing me this entire time I've been in practice. I've watched their families grow. I've watched patients retire, have grandkids, kids. I, it's, it's just a really cool thing to be a part of people's lives. Well, thank you so much for that and what having listened to most, if not all of these Inside Family Medicine episodes, I think this idea of the relationship that you have with your patients is being central to your choice is just really gratifying and really appreciate hearing that from you.

So to get into the topic of the day down coding, Dr. Philip, will you start with just telling folks what down coating is and share a bit about what you are experiencing in your own practice today. So down coding generally refers to the practice of an insurer payer reducing the level of service or the code that a physician is billing.

So for example, if you were to bill a 9, 9 2 1 4 moderate complexity code for an office visit, the payer would. Down code to maybe a 9, 9 2 1 3. And so in result, the result obviously is that you're getting paid less for the work that you've done. What we see a lot of, or we do see in our practice is the, these codes or these coding issues become a real problem because one, obviously you're not getting the payment that you were expecting based on the work that you've done.

And in these times where it's. Increasingly more difficult to run a practice. Costs are, are going up and you know, you're getting paid less. That's a problem. And then the other thing is just in general, trying to deal with that, catch it and fix it is a problem. It, it does tend to be more prevalent, I think with office visit codes and not, of course, as an outpatient physician, that's most of what we do.

And it's those moderate or higher complexity codes where that's a problem. So I'm gonna come back to you and we wanna know more about how you first became aware of this in your practice. But I'm Shawn, I'm gonna turn to you. Sure. I think you're probably pretty well known to most of our listeners, but to those who may be new to our audience.

Yeah. Tell us a little bit about yourself and tell us then a little bit about, not to ask you to get in the head of insurance companies, 'cause I'm not sure we can do that, but why? Why insurance companies might be down coding and why we might be seeing an uptake in this practice. Yeah. So thank you. Yep. Dr.

Phillips, it's nice to be with you today. Thank you for joining us. My name is Shawn Martin. I'm the Executive Vice president and CEO, as Karen said at the top. I, I've been with the Academy about 15 years now in two capacities, oversaw a lot of our public policy and advocacy efforts before becoming CEO in.

2020. I grew up with a family physician in rural northwest Oklahoma, and that's not why I ended up with the AAFP, but it is a life circle moment of kind of that being my formative years was really being around family medicine and then coming back, you know, in this particular capacity, I really came to the academy, built on two promises.

One that primary care was foundational to healthier people and healthier communities. And two, if we could change the economic foundation of. Primary care, we could really change the healthcare system and, and the quality of health that people have in the country. And I still believe those two things to be pretty foundational to the work I do.

But I spend a lot more. Time, you know, supporting our members and making sure that our business and organization is equipped and resourced. Yep. So you can do the work you do and to help Dr. Phillip in the work she does and just 130,000 people across the country. I thought that was an excellent overview of what down coding is in, in real life and, and I think what I would add to that is the down coding is probably an evolution of.

Coding integrity. That has been a, a place in insurance companies for a long time. So insurance companies have long had coding integrity programs for many, many, many years. Those were paper. So you would do paper audits or they would ask Dr. Philip for 10 or 12 charts, they would see how she was coding and as she, you know, do her.

Care notes support a 9 9 2 1 4 2 1 5 and there would be some Ed, you know, education that might take place about a appropriate coding and that would happen across her. Panel and payer mix.

I think what we've seen, we've seen two factors that I think are really driving down coding. One is obviously technology.

AI allows them to do this at scale, on at pace, on a daily basis. That is just unprecedented. And you know, AI is also helping Dr. Philip and our members code and document better on the other side of that relationship. Like there's technology competing with each other, but the scale that it's created is, is.

Unprecedented, you know, by physician practice standards over the last 30, 40, 50 years. The second thing is really there was a lot of public scrutiny on things like utilization management and prior auth, and as that public scrutiny really increased on those programs, I think you've seen. Payers and insurers move away from that, and they've moved to these things that are a little more opaque, a little less visible.

No transparency, because there's just less scrutiny. It's hard, you know, it's harder to tell a story of. You know, they're paying me less per episode of care for this particular visit. Then I have to, you know, go through all these weeks and hurdles to get you the care you Yeah. Need because the, the prior auth impacts the patient down.

Coding only impacts the physician. Yeah. And I, I think it's a business decision, and I don't say that in a pejorative way, but it's a business decision that is, you know, kind of executed on, very subjective. Information and there's no transparency around what that subjective information is. Yeah. So that was a little bit of an academic answer, but I think that's why we are where we are today.

Yeah. So two things. One, just for the record, took us a little over seven minutes to get to you. So the word ai. Okay. In this conversation. Good. Thank you for bringing that forward. And second, I'm not sure every family physician would agree that prior authorization is. Minimized in this case, but I No, no, I agree.

I totally agree with what you're saying in terms of like, this is another strategy that allows them to control costs. This is maybe not as front and center. Yeah, and I think that is at the heart of the issue that I think many practices of experience, and we published an article on this in the November, December issue of FPM, talking about the effect on family medicine practices, really on payment.

Revenue. You know, obviously that's an an a top concern, but also just the administrative issues. How do we find these problems? And then this whole, whole issue of appeal. So, Dr. Philip, if I could turn back to you to sort of talk about like, how did you first become aware of this in your practice and how have you re what have, what impacts did it have and how have you responded to those?

So I, you know, it, it comes from a lot of different places. I mean, one is just information, right? So you see articles about it or you know, I serve on the board for the Texas Academy of Family Physicians, and I also serve as Vice Chair of the Council and Socioeconomics at Texas Medical Associations. So these topics are hot.

Hot button and they come up a lot. So just that awareness first of all, but then knowing, okay, I need to go look for this. Is this actually happening? Because unfortunately, like for, for me, I'm solo practice, so I am a lot more hands-on with my billing and looking at these things. So I do catch it where.

Hey, you know, I build that higher level, but it didn't pay at the level I was expecting it to and catching things that way. I think for employed physicians that may be a little bit more difficult 'cause they maybe are not looking for those things like we are, but it still does affect them, right? Because especially if you're paid on like an RVU model, that is gonna affect your RVU if you're billing the getting paid for these lower codes.

So I think the biggest thing is to really understand your billing. And to keep eyes on that. So whether that's pulling a certain number of charts or claims out and looking to make sure, or making note of those claims that you're billing at a higher level, like a 9, 9 2, 1 5. And that's usually where I see it personally, are those, those, those higher level claims and just making sure that, Hey, am I actually getting reimbursed for what I build?

It's gonna take a lot more active effort to look for that. So I think that's, that's the biggest thing is just. Having an awareness of it and then knowing how can I get that information if it's not something that's readily available to you or easily accessible. So understanding how to navigate your own practice environment is certainly an important starting point.

Understanding sort of the impacts to your practice, but also to you personally as a physician in your compensation. All really important points for family physicians to understand. I think, you know, one of the other things. I guess I would ask about is in terms of identifying this as a problem in your practice, who do you start with?

Is it the physician? Is it the coding team? Is it someone else? Where would you start that conversation if this is something of concern to you in your practice? I think you start with whoever is in charge of your billing or coding is probably the best person to start with because they're gonna be able to pull that data for you.

The other thing is that if you are whoever's doing your billing, if they're just looking for denials, they're not gonna catch this, right? Because your, your client's still getting paid, but it's not getting paid what it should. And so really making sure that whoever is doing that or whoever is monitoring that is looking.

For not just denials, but hey, are we getting paid what we were expected to get paid for this? So that's who it should start. And that may be a different person depending on your practice setting or, or kind of who's in charge of that. But I think the biggest thing that physicians need to take away from this is it's not somebody else's problem.

It is your problem. Like, we need to know these things and we need to kind of be aware of what's happening. I so appreciate that last point, and I think that's such a true statement whether you own your practice or whether you work in your practice. So thank you for really bringing that to the fore.

And Shawn, I think I'd like to turn back to you now and ask Sure.

What's the AAFP doing about this? Well, I I, I appreciate that answer, Karen. It's, it's a little blood boiling 'cause there's just so much important work that Dr. Philip needs to do every day in reconciling her. You know, EOBs and payments is just, you know, probably not the best thing for her community. But I do agree with all the recommendations you guys just discussed.

So, you know, we've been on an evolution with this issue. We, you know, we identified it. If members identified it for us, we, you know, do what we do. Thanks to you and your team. We dig in, we kind of try to understand. You know, one, is this real? Like how widespread is it? Who's doing it? I think our outreach at the beginning was very, what I would call payer specific.

Mm-hmm. I think we were communicating with the individual payers like, please don't do this. Why are you doing this? And as that, as those conversations evolved and matured, we began to reach out to, you know, the Insurance Trade Association, ahip and others as we didn't get the responses that we were expecting or anticipating.

Hoping in those conversations, hoping for, we're hoping for in those conversations and as the use of these programs mm-hmm. Spread, you know, they became very common, very quickly. We actually, you know, communicated with the government and we wrote a, you know, what I thought was a very thoughtful letter to the Department of Justice and the Federal Trade Commission and to the Centers for Medicare and Medicaid Services, and pointed out a, a, a number of concerns with the use of down coding, but we really centered on the fact, uh.

I think three key points. One, it was detrimental to primary care. Like primary care exists on very narrow margins. These types of programs are really, you know, a disadvantage to those practices, long-term economic stability. Number two is just the lack of transparency on what was actually happening. I think we.

Spent a couple of pages just talking about the fact, uh, coding integrity programs have always existed. Yeah. They've been transparent and honest about them. Why is this happening? Why do insurers think that our members are. Inappropriately coding, why aren't they showing that information so that there could be an open dialogue about coding integrity between our members and their and their payers.

And I think the third thing, which really bothers me a lot is there's no appeals process on many of these programs. Now. Payers are starting to put appeals process back in place. Yep. But in the early days of these programs, like it. You just got paid what you got paid, and there wasn't an appeals process for our members to, to pursue.

And I think all three of those things independently deserve letters. And I, I think, you know, this is where our advocacy is really taking hold now, moving forward, you know, we're talking to Congress, we're using our public affairs mechanisms to raise awareness both with our members and with payers. We continue to have conversation with the insurers about these programs.

So there's, there's a long way to go. Yep. I think the fact that there's now an appeals process is reflective of our advocacy and other group's advocacy of at least, you know, at minimum you've gotta put some things back in place for physicians to ask questions about what's happening in their relationship and contracts with you.

But, you know, I think this is a hot topic for 2026. I think it will continue to build and we'll see, you know, what it takes for us to be successful for Dr. Yeah, and I think one of the things that we've expressed in our letters publicly with payers and with others, but I think it's important for family physicians hearing this to to know is that one of our central concerns is also that this will.

Cause physicians to intentionally under code. Yeah. And undervalue their services. Services. And I, I'd like to turn back to you, Dr. Philip, and ask you for your reaction to that because I think that we already have concerns that maybe physicians are not always valuing their services at that level. They need to be valued and just to sort of avoid this or be.

Even finger pointed as someone who might be overcoding is something that we know the integrity is misaligned with the integrity of family physicians. So I, I'd love to hear your thoughts on that. And is there, are there things the a FP could be doing to, to help empower physicians to avoid that, that trap that they could fall into?

In general, I think that a lot of physicians do under code as a rule because maybe you've been taught that, that you know, you, you shouldn't have too many higher complexity visits or too many codes of, you know, this level and that's. If you've done the work and you've documented the work, then you should bill for the work that you've done.

It doesn't serve anyone to under code and not accurately reflect the work that you're doing and pay. Patients are complex. Family medicine is a complex specialty, and we. Should actually accurately diagnose and, and treat and code for that and be paid what we, for the work we've done. You know, the other point about this, you know, the appeals process and, and it's great that that exists, but it also creates another burden for physicians to have to appeal this and to have to put in that extra work to prove that we did the work that we did.

Right. So while, yes, it's a step in the right direction, it is still another burden for physicians, regardless of practice setting to have to prove that we did the work. Yeah. You know, one of the things that we have continually pointed out in our communication about this, especially to those with any sort of regulatory authority, is that this is out of comply.

The what? The way that payers are doing this is. In our view out of compliance with CPT guidance. Yeah. Which, you know, says you can't base the, you know, payment or, or level on the diagnosis code solely. And that's essentially I think what payers are doing and Ben asking for all of the data. So I think your point about the appeals process and the complexity of that and the burden that it places on physicians is really, really well made.

Shawn, is there anything you wanna add before we close about what else you would want family physicians to know about this or maybe proactively do? Yeah, I think there's a couple things. One, let me talk about the resources we have available. I'm very appreciative to our team here at the AAFP and and your team.

Specifically. We have CPT coding and documentation resources that help you understand how to best, you know, document your services and value your. Time and services to your patients. We write a lot of blogs that really should not, probably not be called blogs. I think we call them getting paid blogs.

They're really, you know, they're kind of compliance best practices. Yeah. Type communications that help physicians understand some of these nuances that are taking place or shifts in the marketplace and how. Uh, to be aware of them first and foremost, how to advocate for yourself, and then also how to kind of drive some policy changes.

I think the third thing is we have a lot of resources available, uh, on our website for you to do self-advocacy, either with your payers in your state, with the federal government, with your members of Congress. We make it easy for you to communicate your concerns about. You know, down coding and other types of payment practices, but any variety of other issues that, you know, it's important for people that are in these positions to hear from family physicians.

I think they, I think these issues become white papers. Mm-hmm. And, you know, they, they lose sight of the fact that they're actually are. You know, fabulous family physicians in Round Rock, Texas that, you know, this impacts their life in, you know, real and consequential ways on a daily basis. Sure. You know, we do a lot of storytelling.

I think the other thing I, I think Dr. Phillip just said something that really triggered a really key point for me is like family physicians understanding their value and being compensated for that value. And I think it is, it is easy to say, I'm gonna. Put 2 1 3 and so 2 1 4 because six weeks from now I don't want to have to deal with, you know, this other potential issue.

And I understand the human behavior behind that, but I would just encourage everybody to fight that you, you know, the value of your services should be compensated for what they are. And I, I think it's just important for family physicians to continue to, to hear that. So, but I do, we have a number of resources, AAFP dot org you can find those, help you navigate these issues.

Yeah. Thank you for that. And Dr. Philip, I'd like to turn to you to give you the last word before we close out this important conversation. Anything you'd like to add? Well, I mean. This is an important topic. It really, truly, there's so few physicians who this rule should, these rules should apply to in terms of down coding.

I think, you know, just keep, keep doing what you're doing. Keep you know, fighting the good fight, taking care of your patients, and then just be cognizant that it's an issue and it's something that we need to really work on and stay on top of. Yeah. Well, thank you both so much for joining us today and talking about this really important topic and its impact on family physicians and actually actually acting as their sort of biggest cheerleaders and supporters.

I mean, I don't wanna trivialize the issue by using those terms, but I. You know, knowing your value, knowing your worth, and really standing behind that is, I think, really at the heart of this. So, to our listeners, if you'd like to learn more about coding for Complexity or you know, and combating down coding, you can have, we have links in the show notes, and you can find everything you need on AAFP dot org.

If you enjoyed today's episode, let us know by dropping a line to aafpnews@aafp.org. And be sure to share this episode with your friends and followers on social media. And tag the AAFP. Thank you for joining us.