What Is Downcoding And How Do PIP Insurers Use It Against You?

Downcoding is the PIP insurer’s solution to reimbursing for a less extensive evaluation.  Please continue reading to understand why there’s money to be made.

WHAT IS DOWNCODING

Downcoding occurs when the PIP insurer unilaterally makes a decision to tell you what to bill for an evaluation (in most circumstances).  Generally, an insurer will argue that your medical decision-making was not complex, or that you did not obtain a comprehensive history, or that you did not spend enough time with the patient based on your medical notes.  The PIP insurer makes this decision without seeing the patient at all!  This situation usually appears in the context of new and established patient office visits.

MONEY YOU ARE DUE AND OWED

The PIP insurer downcodes from a 99205 to 99203 office visit. For example, for a 2016 date of service, this downcoding will cost you approximately $166 and change. This can become significant if the insurer downcodes on multiple patient visits. We are here to ensure and fight for your rights. The insurer cannot downcode whenever they please. The Florida PIP statute and case law protect you.

INSURER MUST CONTACT YOUR OFFICE PRIOR TO DOWNCODING

The Florida PIP statute (627.736 (5)(a)(5)(e) requires the PIP insurer to

1. Contact the health care provider and discuss the reasons for the down coding and
2. Discuss the reasons for the provider’s coding decision OR
3. Make a reasonable good faith effort to do so, and document such in the PIP insurer’s file.

Steps 1-3 ARE MANDATORY.  An insurer must call your clinic to discuss the downcoding and ask you why you coded the way you did.  If the INSURER fails to call you, we will file suit and ensure you are properly paid.

PIP insurers rarely call health care clinics to verify downcoding. You are certainly entitled to the difference between the code you billed and the amount the PIP insurer reimbursed you. Fight this fight and allow us to win you found money that is rightfully yours!

HOW TO ENSURE YOUR MEDICAL RECORDS RISE TO THE LEVEL OF A COMPREHENSIVE EXAMINATION FOR DOWNCODING PURPOSES

1. Remember to always ask for a detailed history from your patient. Be sure to discuss:
   1. Onset date of his/her pain
   2. Type of pain/region of pain
   3. Past history for motor vehicle accidents/other type of accidents
      1. Time-frame for resolution of pain for each incident
2. Perform a detailed subjective/objective examination
3. Plan of care requiring complex medical treatment plan
4. Document the amount of time spent with the patient in your medical notes

Insurers will look for any of the above pieces of information.  If they find any one piece missing they will downcode. It is important to cross your Is and dot your Ts to ensure everything is included within the medical notes you send to the PIP insurer particularly with the first HICFA.

WHAT TO DO IF THE INSURER CALLS YOU:

Certain insurers are beginning to call health care clinics to discuss downcoding. Here is what you should do if the insurer calls you:

1. Explain your reasoning for the initial billing.
   1. Only give information about what you are asked. Contact us prior to sending any requested documents to the PIP insurer.
2. Get the adjuster’s name, credentials, and department information
   1. This will help us for litigation purposes.
3. Ask the adjuster/medical claims representative why they are downcoding.
   1. Will provide us with the basis for Defendant’s downcoding and the reasoning behind the said defense.
4. Ask the adjuster/medical claims representative what they are disputing regarding the medical records.
   1. This information will allow us to determine with which aspect of the evaluation the PIP insurer has an issue. Their issue could be as trivial as the patient’s subjective complaints.
5. Indicate your disagreement with the PIP insurer’s decision. 
   1. The PIP insurer will certainly note that you voiced agreement to their decision potentially precluding a lawsuit in the future.  Make sure to voice your objection to the individual calling to explain the downcoding.  Ask for an email to which you send and document your vehement disagreement.

MOST COMMON DOWNCODED BILLING:

Outpatient office evaluations/consultations

1. EX: 99215 downcoded to 99213
2. Typical Insurers:
   1. Progressive, USAA

You may also see certain MRI’s and chiropractic CPT codes reduced or altogether not paid because PIP insurers believe you upcoded the treatment and that the treatment billed  was not necessary.

DO NOT GET DOWNCODING AND TIME CUT-OFFS CONFUSED

We litigate all PIP issues.  We do not cherry-pick cases.  IME cut-offs are a different defense altogether from downcoding.

IME-PIP insurer utilizing a doctor to opine that treatment was not reasonable and/or medically necessary and/or related.  Here, the insurer is cutting off treatment and will not reimburse you.

Downcoding-PIP insurer codes a higher reimbursed service down to a lesser service and ultimately pays a reduced rate.

WHY YOU SHOULD CALL US

We have experience litigating all PIP issues throughout many jurisdictions. Downcoding is a common issue we see and attack.  We have the proper pleadings, forms, and the like to be successful in obtaining the money you deserve.  Our litigation team will assist you throughout the entire process.  We also offer lunch and learns to educate your health care clinic about the newest findings in PIP.  Give us a call immediately and let us find you PIP money!