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The first best way to stop payers from downcoding your claims is to make doubly sure they are correctly coded and documented when submitted, say experts. But if you believe you are being treated unfairly, don’t be afraid to fight back. Here are some steps you can take:
1. If you believe your claims are correct and your bills are still getting downcoded and denied by claim reviewers, most experts advise that you not waste any more time with accounting clerks and instead take your complaint up the corporate ladder directly to the plan’s medical director.
2. If you don’t get any satisfaction from the medical director, then quickly file an internal appeal. To help navigate the appeals process, make sure you keep detailed notes of what you’ve done to resolve the disputed claim — and who you talked to at the plan.
3. It’s also wise to report any suspected instances of downcoding to your local medical society or hospital association, which may track complaints to determine if it is an isolated incident or part of an emerging pattern.
Tip: If unhappy with how you’re being treated by plan payers, you may want to add some political clout by asking your local or state medical society or hospital group to intervene on your behalf.
4. The next stop on the complaint chain is your state insurance department. State regulators are often reluctant to get involved in individual payment and contract disputes, but the fact that you’re filing a complaint will give you added leverage by raising your case’s visibility another notch. Plus, if enough providers file complaints, this puts more pressure on public officials to do something about the situation.
5. If all else fails, James Wieland, a Baltimore health care attorney, advises you to take the plan to court. "I have had good luck taking, or threatening to take, a carrier to arbitration or small claims court," he notes. Warning: Only go down this road if you are sure your claim was properly coded and if you have the documentation to prove it.
Here are some other key factors to keep in mind:
• Keep accurate and complete records. Without this, you don’t have a legal leg to stand on.
• Have a good contract. Review any contract before you sign it. Most contracts spell out reasons for downcoding and what the physician can expect during an appeal.
• Follow procedures. Make sure you’ve filled out the claim correctly. If a claim comes back, call the claims administration and check to see if more documentation is necessary.