On this episode, Increase Down Coating. Is the appeal juice worth the squeeze?

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Welcome to episode 303 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter, Dr. Ray Painter. And we want to welcome back special guest, Mary Ann DeSoyce. Mary Ann is the COO of PRS Managed Services. That's our RCM group. So we want to thank Mary Ann for joining us today.

Thank you for having me.

All right. And let's talk about down coding. And this is something that we're seeing more and more of. And it's just we've talked about this uh several times on the podcast recently, but it just seems to be never ending. Mark, Mary Ann, what do you guys what are you guys seeing in the trenches out there?

Well, so Marianne ran some numbers in June, and we actually saw about a 26% increase in downcoats from the payers in a single month. So it's really taken off from that side. We do know that there are some lawsuits out there that are trying to get the payers to back off of this. But when you look at the numbers, and again, we'll just use some round numbers at this. That the average savings per claim, if they downcode without any more work from the payer, is 40 bucks a claim. So that's just dropping from a four to a three based on Medicare rates. So that's a round number. It's a real number, but it could be higher than that. Obviously, if they're dropping you from a five to a three, that's a bigger hit. Some of your payers, you're paying, you're getting you've got 120% or 130% of Medicare, which of course increases that dollar amount as well. So all of those things take into account. So essentially, I just doing a couple of back of the napkin numbers, right? So if you have 100 down codes in a month and you do nothing about it, the insurance company is say four thousand dollars and you've cost yourself or they've cost you through their bogus practices four thousand dollars and you run that across multiple physicians, it's I mean, the it's there's the numbers are flat out, they're just staggering what's going on. And even if half of them don't get say get don't get appealed. You can see that leveraging that across multiple practices. And the other piece of this that I have to say we're seeing, and Marianne, you can jump in on this, is the amount of work that this is causing the practice is just adding to the stress, and there's collateral damage that comes through. So if you're taking the time to work some or all of these down codes, where is that time coming from? So if they're denying, payers are denying other things or there's a problem with a particular claim like a prior auth or a missing modifier. All of the things that really filled up the day of a RCM team, of an efficient RCM team, there's no time left to actually process these other claims. Now we've done some calculations across the board, and we figure that essentially an individual on an average day can probably process somewhere around 50 claims that have been downcoded given the activities that have to take place. Grabbing the records, collecting all the information, resubmitting it to the payer portals. So that's uh as you start backing things down, and we have some folks that are a little more efficient because they do this all day, every day type of things, but essentially that's a rational number to take a look at. That's you know, that's a tough thing to pull off of the plate. So if you're getting an average of 100 a day, you know, essentially you're looking at an FTE spending about two and a half hours or two and a half days of their week to actually process these claims. So, I mean, those numbers really, as you start running them up the flagpole, are rough. And it's taking its toll and it's really showing through burnout, frustration, and increased ARs if you find it. Now, one of the things that the payers have figured out is a better way to process these as not denials, but as adjusted payments. So they aren't showing up on your AR. So if you've got an overloaded staff and they're being measured on how they're doing relative to what your AR looks like, what are they gonna choose? If they're not supervised and directed as to what they should work on, they're gonna focus on those things that affect their measuring stick, which is the AR, which leaves a lot of these down codes off. So you're talking about lost revenue in a lot of cases, because that is where, based on metrics and based on overall measurements, you can see why an individual RCM individual being measured on their AR and how the AR looks, or that's their main focus, that's not gonna fit the juice that they need to actually squeeze. So those things get left off the table. So it's important from a number of reports and a number of different ways to look at things to monitor what's happening in this area. So with that kind of general background, and I'll also tell you that we did a quick project where we, and I'll have Marianne kind of wander through exactly how we're attacking this across multiple clients, but we with that increase until we could get our workload shifted around, we had to basically take 10 people and dedicate half of their time to run through 1,600 claims for that initial bolus of down codes that came in. And you know, if we measure things from a you know reasonable level, we figure that cost us about $5,400 across the board. But the return to the practice was about $64,000. And if even if the practice did the bare minimum of 70% to get off of that down coding wheel, that would put it at $48,000, $44,000. So it is, when you look at it in direct numbers, something that you can make the time to make these to go back on these things. But it is daunting and it is disappointing that even with all of these claims getting shoved back out the door from a lot of our practices, they aren't responding by cutting down the number of down codes. That was one of the things that we were hoping, and we've seen in the past that once they figure out that a practice really knows what they're doing and they're winning most of their claims, that they'd back off. And what we see is that they back off for a period of time, but it's not as long as we would like it to be. So they may see some value in burying the RCM team and the workforce of physician offices in busy work relative to these down codes. And it's not a a pleasant thing to say out loud, but boy, it sure looks like that at this point in time. So, Marianne, can you walk through kind of the workflow that you've established with our team to kind of balance out staying on top of the AR, which is important. We need to make sure we're working the AR and the important things, especially those high dollar claims. And then with the down coding that we're seeing across the country.

So what we've had to do is because we've seen such an increase in the down coding in 2026, and really just in the past 120 days, it's been significant. What I've had to do is work with the teams to establish that this is not something that's decreasing. It's actually increasing. So when we're seeing denials fall into buckets and we have prioritizing their workflow, we've had to come to a realization that it is easier for in what I've seen, it's easier if we have a dedicated a lot of time for the staff to work down coding and medical records requests. I kind of put them in the same bucket because it is the same process. We're uploading medical records, we're putting in a stating a statement of reconsideration on the websites. So what we've had to do is prioritize that, for example, on Fridays is when the team will work. They work their regular workflows in prioritizing their RCM. They work their denials, their rejections, their invalids every day. And then they go to their AR, their outstanding aging claims, Monday through Thursday. And then on Friday is when we're tackling the downcoding and medical records uploading. And that allows a more efficient workflow for people to be just dedicated and clicking. And it's not just clicking, but it is a lot of getting on the Availity website, plugging these things in, pulling up each claim, attaching it to the item, making your note and your practice management system. So if it allows no phone calls to being made that time and we can get through a little bit more of the workflow. So knowing that this is going to be a standardized workflow that we have to incorporate into our daily work, we've kind of just worked it out to make sure that it's done once a week. And if we have a clinic that has a higher volume, let's say they have three or four payers that are down coding, then we might have to add a second half day in that work week so we can tackle that. That way, what I've found is that you're letting your staff know, okay, this is a priority and this is a necessity of our workflow. We need to get through these. However, we do not want to ignore everything else that's coming in, your 22 modifiers that need medical records processing, your high-dollar drugs that needs something, an invoice sent on them. We don't want that being prioritized because of the volume of the down coding that's coming in and medical records request. We don't want them to just focus on those denials and leave those other things aside. So really prioritizing the workflow, knowing it's there. And secondarily, is running an actual report that we do at I'm running them every two weeks to make sure that we're not missing a different way that possibly these things are coming in through electronic remits. And so that way we can identify that A, they're getting worked, B, they're not getting written off for another denial reason or another adjudication reason, and that also that we're making sure that all of these are going out within the time span that each payer wants those back to them.

So, Marianne, how much of the record requests that go through to the insurance company do we stop and review those records? I mean, that's an additional time commitment that potentially has to be figured into the equation.

Correct. So we have a checklist process that we have the team go through. They're pulling those records and reviewing them. And we've really worked with our staff and continue to work with our staff to know what they need to identify and what needs to be, what we can push out to the payer without review from a coder and what possibly needs to get stopped and reviewed for a coder. So we kind of make sure that they understand what they have to pull, the the complete medical record, making sure that not just the note goes, but any testing that they might need to have attached with that medical record and also what needs to be stopped. So for example, if a doctor has overridden a note and hasn't actually used the algorithm behind a practice management system to identify a level four or level five, those ones would be ones that we would want to have somebody review to make sure it met those requirements before we send them for a down coding appeal so that we don't actually trigger more requests to us. Because if you're sending items to the payer in a large volume that actually do meet a level three and they see that they're going to probably increase your down coding and not decrease it. But if we're reviewing those on a quick checklist, then we're able to send those through and do that in a proficient manner. Not every claim needs to be reviewed by a coder. And when you're educating your AR team to understand that these items have been met for a level four, level five quickly, you can have those get processed a little quicker as well.

Yeah, and I've heard there are also plenty of practices out there that don't have, you know, some of their EHRs set up the right way, or you have specific physicians who we know don't use the ER in the right way, but they're good coders. So do we, I mean, I'd so I've heard of some groups that do limited review based on the physician that's out there and the type of service that they provide. Is that something that gets leveraged and you've heard or we use as well?

Yeah, so exactly that. When you're working on a compliance measure and you're doing, you're saying that they're, for exact example, the the provider you know is 80 to 90% successful on their EM audits that you've done, reviews you've done on them. And also as you're sending in appeals, you know their success rate on their appeals are at that 80-90%, depending on the metrics each clinic has. Most of them are 80% or over. Then yes, we're also letting, you know, your AR team knows that Dr. A, obviously, we don't need to pay as much. He's a great coder, he passes all his audits, he's at 90% success rate on his appeals. We're putting those through knowing that. But a provider that possibly is new, newer to the practice, newer to urology, we would put those as items that might need to be have more attention sent to them from our AR team and sent over to a coder to review. So, yes, that that is a consideration as well. Also knowing your practice limitations as well. If somebody, sometimes we know that a practice has a second person reviewing every note that a provider does in their EHR systems. So we know we don't have to review those again. So when we know those, those items in a practice, we know we don't have to review them and we can kick them out. That also allows you guys to prioritize differently because if you already know those metrics are there for Dr. A and not Dr. B, then you could also say these can be done by an entry-level AR person where you can put them on an availability system, processing those and just sending the records, where maybe Dr. B needs to have somebody that's a higher level to be reviewing those EM codes.

Yeah. So smart application of your staff, yes, prioritization. So it is really a workflow in some degree by a physician, but within each practice for us.

Correct. And also allows you guys to, you know, really review. If you have five providers in your practice and you have two that has that higher volume, it's really like, what do we need to do with that provider and educating that team so that we can get a better output at the beginning so that we can then turn over at the backside with the AR team. We now have taken those two providers where we've done work on the front side. So we now know they're more in compliant and we can actually process these quicker on the back end. You know, we've talked about this a number of times. This industry has changed where years and years ago we could pretty much appeal or work anything after it was denied once it came back to us from the payer, and that you were able to correct things, you were able to ask for retro authors, you were able to make addendums to records. We're now in a place in this industry where that's not really possible. There's time limitations to turnaround on appeals and denials. There's many things that the payers have placed in that we can't appeal once the claim has been denied. There are addendums that can't be made. So we really want to focus on when you take that item and you know that a doctor is taking more time on the review, you want to apply that. How do we fix it in the front end to make this better so that claim goes out and we know that record is supporting that that claim?

Are the down codes impacting every practice? Or are there some practices that you see that just aren't impacted?

Usually some some of the rural small, smaller practices in town aren't being affected as much, but I that is rare. I have literally in the last 60 days probably I don't have one clinic that hasn't experienced down coding now that we actually work full RCM for. So there is probably practices that haven't seen this. But I also want to be aware, also if you haven't seen it, it might be because you weren't actually aware through an ERA, yeah, through an ERA that they have been actually doing this to you and you may not know it.

So if you if someone's listening to this and they think it's not impacting them, they should probably go take a look at the Correct.

I would pull a transaction report, however that comes out of your system for you know 60 to 90 days. Let's just say a Blue Cross Blue Shield payer, you'd want to run your 99214s and your 99215s along with your 99204s and 99205s and run what your allowable and your payment was. I've been able to find on a number of clients where when we run that, you can see that you got paid sometimes at the level four from a a payer, but then all of a sudden you see a payment is $40, $45 less and it's not their copay. You actually see their copay being posted. So you can actually see that yes, the claim went out as a $99214, but the payment that came back to you was for a $99213. You're able to see that if you run the transaction report and compare those payments. You can look at your remittance advice codes as well, but usually if you aren't aware that you're having that done, it's usually because the payer is processing the claim with the adjustment that allows the math to work for that original 99214 code or 215 code. So sneaky. It is, and it's been challenging for a while now. I believe that it's been here for quite some time, but this year alone, it has been, and it changes. The frequent they'll deny it for frequency, they'll deny it for medical necessity, they deny it for just an adjustment, they'll put in this 226 code. It's an interesting process that they're doing, and each payer is different. Even different states with the same payer, a blue cross of Florida versus a blue cross of Georgia, those things as well, they do different processes.

Ray, comments, questions?

Wow. What a lot of info in a short period of time. But a couple of things. One, you've made it very clear that you have to code what you document these day and time.

Yes.

You don't get by with having a level three documentation and charging a level four. And number two, the key point is that if you check your claims before it goes out to know that your documentation is accurate then the work of appealing is not near as much. Correct. And now I have one question. Mark, you made a monetary report on this. What do you say the doc that says, oh I can't we can't do all that work, I'd have to hire another employee.

It's an ROI calculation. Right? How many down codes are you getting?

Yeah.

Could you hire another individual to get that extra money? Is that worth the time? So you know that's one of the issues that's out there. And you know I would have told you before that it was always worth it to try and back the payer off. But we're not seeing the payers back off even with our good coding groups. So as much as I'd like to tell you it's always worth it may not be for some practices. I think it's worth it for the majority of practices. But if you're seeing because Humana is only one percent of your practice, you know, you might be better off dropping Humana and skipping all of this stuff than trying to fight Humana. It's like I mean that's those are all the calculations that you need to take into place. It's not as simple as the principle. And maybe the real principle is if it's a crappy payer they probably have crappy patience, crappy service you don't want to be part of their crappy machine. So you gotta think about that. There's plenty of patience out there. Now if it's a big payer with a lot of your revenue and a lot of down codes, then that one's worth fighting because my ROI is there. So it's a case by case basis. And I again that's it turns my stomach to say that because we've always said that you should fight and fight. But it's now becoming a game of numbers and a and really a a game of returns and ultimately to stop the bleed your better move maybe to run from the knife.

So but but you can get off this but what happens so what we've seen is we have seen providers and practices be removed from the what I've been referred to as the algorithm for which they've placed at the payers if you for example if you pass 70% which is one of the algorithms I was given they the provider should be taken off of the automatic down coding. However what we're seeing is that can last from anywhere from months to a week. We've actually seen a provider come off of the algorithm and then immediate within a week come back on. So you can see a time period of June 14th through the 27th where they were off of it. And then immediately we saw the down coding when we called it's like oh well they were off of that but it was it there's an automatic rotation and the system has picked that provider back up. So those are the things that we're fighting with on the payer end because they're following what they're telling you. They've removed that provider but that doesn't say that they don't put that provider right back in that algorithm. Also you can have providers in your practice that are on you know the down coding and other providers that have come off. And so it is you can really never take your finger off the pulse of watching this. So you can think which we did we you know we've seen practices come off of this you can think that you're off of it for good for that payer but you need to make sure that you keep that monitoring system up to make sure that you continue to check the things you were checking before your reports, your denial reasons, your write-offs, all of those items your allowables and making sure that you guys are paying attention to that because it will most likely come back on. And also don't think it's limited to one payer. We're seeing this increase with numerous payers and we're seeing payers adopt this even as recent as last month. So just making sure that you also know that this is not just one payer specific this is a trend that seems to be heading out to most of your major payers.

Chase I wanted to add in all of this stuff the discussion of ROI really was directed towards the practice and just to let you know that as an RCM group we don't have that same option right so our issue we're paid as a percentage of collections and our contractual commitment and our commitment as a revenue cycle management group is to collect every dollar. So from our side and this is would also apply to any practice that's working on the side the of fighting all these down codes is how do you get as efficient as you can? Now we're leveraging workflows and individuals but we're also working towards AI tools and what can we do to leverage our people and our processes to make sure that we can put those things into practice that allow us to build that ROI. And as you look at this you probably want to pull a little bit of that calculation into your practice as well. Like what can you do to make things better or is it time to look at finding some additional resources or some assistance that could help you do those all of those things I think have to be part of the overall calculus. And I think we're seeing that as we're getting more and more physicians contacting us about what can we do to help them in the revenue cycle flow, the workflows, because it's just becoming too much to manage on their individual scales. So it's a tough balance but it's a different workflow and a different focus as a dedicated RCM group. And you want to make sure if you're using somebody who is outsourced on the RCM that they do take the right attitude towards this and you'll want to watch them.

Yeah. And I want to add to that piece what Mark is talking about with that front end piece of it and getting that workflow done. Also make sure in your workflow is the follow-up of those claims and managing the expectations of what's happening on your aging your AR because your aging report will increase. For example, if you have a Humana payer that's down coding every one of your 99214s, 204s, 205s, and 215s and you appeal all of those, they will stay on your aging and increase your days in AR because they will most likely stay on your aging for a Humana payer for 120 days plus because their turnaround on your appeal is at that point at that payer. So really making sure that you whoever if you guys are whoever's driving that RCM component to educate the administrators in the practice, letting them know, hey, I've got 800 claims on the aging that we've appealed but they will probably not cut they will age to the 120 and making sure that you know that those things are on there, you have a follow-up plan to monitoring that to make sure your appeals are processed, but really just making sure managing that expectation because what we're seeing now is that several years ago we were saying don't ever have aging over 45 days. Well really and truly in this industry now that's a rarity anymore because your claims and your appeals process, AI is kicking these claims back to us at a rapid rate, but the payers have not been able to figure out how to use AI to process the appeals we're sending back to them in a timely manner because that's the staff that's used to review those. So knowing that's going to increase your days in AR, knowing that's going to be on your aging for some time is really important to make sure that the providers know that though that's why that AR has increased.

I think that's a great point. All right well let's let's wrap this episode up here we want to thank modmed for supporting this episode. If you're in the market for any HR or practice management system you can go to modmed.com for specials for our listening audience. All right let's get some final thoughts and we'll start with Mark then go to Ray and then give the final word to Marianne.

Mark final thoughts yeah this is you know obviously a frustrating tactic and generally falls in the completely unfair and manipulative BS category. But as we deal with things until it can be changed we have to deal with this. I think there are some fairly aggressive things that you can think about outside the box. If you're going back for contract negotiations this might be something that you add in based on your statistics that they can't downcode you according to according to contract. Maybe that's more important than getting an extra point or two from the payer. So don't leave that off your arm your tool bag as you go back to contracts. Think about lawsuits this can't be right. It just doesn't feel right it doesn't smell right. Yes they've found some legal loopholes to do that but there's got to be a lawyer out there that can figure out how to shut this down. It's one of those things that it has to be really somebody who experiences the damage. So that's one of those things that is a bar that needs to be in there. Maybe it's a class action in a particular area state legislators could potentially focus on at least some of the commercial pieces but they won't be able to touch ERISA or the federal program. So that has to be national so it's once again time to consider connecting with your legislators both at the state and federal levels and start talking to them about this ridiculous practice. Physicians are getting cut enough as it is we don't need any more so we've got to strike back as in all ways possible legislatively contractually and of course until it's fixed with just some good workflows and labor.

But the bottom line is we've seen payers in the past that if you don't check their denials they just do more denials. They're in the business of making money but if they are if you're going to keep the payer appeal everything because they're in the business of making money too and if we can cost them more with the appeals than they're making they'll quit. They're obviously making a lot of money right now on your skin.

They're drinking your juice carry that analogy over all right Marianne final thoughts I just want to make sure you guys are aware of what's happening in your practice and making sure that you guys are s aware of what is being down coded if you aren't being down coded to have a policy in place to make sure you're reviewing for this because it will most likely hit your practice. And as Mark was saying before I mean identify if the ROI is worth it. But as I've worked here for 20 years it when you don't appeal these things, when you don't reprocess them, then they keep that that money instead of you guys getting it that the payer, the provider who actually saw the patient, the practice that should get that money. So thinking of that as well as you know yes, it might be a little bit of a lift but finding out how you prioritize your workload to make sure you can get to those things instead of just ignoring them is the process I would recommend you taking because your that $40 your when you guys are adjusting your collection rates, when you guys are reviewing what you've been paid each year, each provider, those numbers are significant when the majority of your practice is EM visits. So make sure you guys are appealing those things if you can and if you can't maybe look at resources like Mark was saying before that would help you get those those resources done. And in the end, education to your providers on how to document so that you could actually come up with a process where maybe you do use AI to push these out to your payers and you can find a way to do that because you don't have to review the documentation because you know your providers are documenting what they're supposed to be for the levels of service that are being billed.

Great point. All right we want to remind you that the Urology Advanced coding and reimbursement seminar registration is open and we do have a Labor Day special going on. If you go to PRSnetwork.com right there on the home page is a link to register and more information about the seminars and you can use the Labor Day special code of 27 UAE that's 27. All right also want to remind you that the hub is up and running the PRS Urology coding and reimbursement hub we did add some additional pages and categories so we encourage you to check that out and we're adding I know we got a lot more stuff coming on in the next week as well so I want to try and make that as useful as possible. So keep checking on the hub and all the information we have on that hub and you can go to PRSnetwork.com forward slash urology hub to access that all right that's all we have for today and we want to thank Marianne for joining us. We appreciate all that great information that you've provided us and thank everybody for listening take us out right happy coding filling and the people thank you for listening to the R decoding reimbursement podcast where we help urologists and their staff maximize income and efficiency so there's time and energy for patient care and a happy life special thanks to our pointer for music today you can find on Spotify under its record label YouTube