Wiki Molina is automatically downcoding office visits without requesting medical records.

[mforsyth]

I do billing for an internal medicine physician who specializes in weight management.
Most of his visits are coded as 99214 or 99215 + 99401 or 99402.
We do not have a lot of Molina patients, but of the ones we do have, every single claim gets downcoded from 99214 to 99213.
We do not receive a notice in advance. We do not receive a request for medical records substantiating the charges. Molina just automatically assumes we chose the wrong CPT code.
Interestingly enough, it seems 9/10 times if we just use 99214 or 99215 without any weight counseling code, it does not get downcoded.

Is this happening for anyone else? How do we prevent this from happening? Is this illegal for them to do this?
We are just upset that they aren't requesting documentation before doing this, and our provider really does spend the time and energy providing these services to his patients.

 

[thomas7331]

It appears Molina has policies stating they will do this: https://www.molinahealthcare.com/pr...roviders/il/Duals/Provider-Memo-EM-Coding.pdf

Although it doesn't specifically say what criteria they are using to make these determinations, the way it reads suggests to me that they may be basing it on the diagnosis codes billed on the claims. It does say that providers may appeal the determinations if they don't agree with them.

I would certain be upset with them for doing this without reviewing documentation too. They are effectively deciding that your provider is 'guilty until proven innocent', which payers sometimes do in their claims policies. However, if your provider is contracted with them, then the contract likely has a clause that says your provider will abide by their policies, so there's probably nothing illegal about this and not much you can do. If this happens a lot and is costing the provider a lot of lost revenue and/or time spent in appeals, then you might make a case to your provider that it may be more cost effective just to exit the contract and stop seeing these patients.

 

[mforsyth]

It appears Molina has policies stating they will do this: https://www.molinahealthcare.com/pr...roviders/il/Duals/Provider-Memo-EM-Coding.pdf

Although it doesn't specifically say what criteria they are using to make these determinations, the way it reads suggests to me that they may be basing it on the diagnosis codes billed on the claims. It does say that providers may appeal the determinations if they don't agree with them.

I would certain be upset with them for doing this without reviewing documentation too. They are effectively deciding that your provider is 'guilty until proven innocent', which payers sometimes do in their claims policies. However, if your provider is contracted with them, then the contract likely has a clause that says your provider will abide by their policies, so there's probably nothing illegal about this and not much you can do. If this happens a lot and is costing the provider a lot of lost revenue and/or time spent in appeals, then you might make a case to your provider that it may be more cost effective just to exit the contract and stop seeing these patients.

Ah, thank you! I had been looking for this kind of information but did not know how to word it in the Goggle search bar. Thank you so much!