Insurer ED Downcoding Policies Struck down by Surprise Billing Rule

VACEP, allies, send letter to HHS and CMS to urge strike-down of Virginia budget item

This week, the Biden administration released an “interim final rule” outlawing balance billing but also prohibiting insurers from retroactively denying emergency department claims.

As we’ve explained, “downcoding” by Medicaid and insurers is a growing problem that threatens quality and access to care, as well as fair emergency physician reimbursement. Last year, VACEP and our partners began battling a damaging state budget item that dramatically reduces Medicaid payments for hospital emergency department visits. In addition, UnitedHealthcare announced in June that they would begin retroactively denying some emergency claims — a policy it quickly backed away from with pressure from ACEP.

This week, VACEP and our partners at the Virginia Hospital & Healthcare Association and the Medical Society of Virginia sent a letter to the Secretary of the U.S. Department of Health and Human Services and Administrator of Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services. Our letter helps inform them of this new interim rule to ensure it isn’t overlooked.

But the letter also serves an additional purpose: To urge CMS to reject Virginia’s budget item (the “Downcoding Provision”) that is automatically reducing payment to emergency physicians for nearly 800 diagnosis codes (more background here). Beyond our continued assertion that the Downcoding Provision violates existing federal statutes and regulations, it is in clear conflict with the policy adopted by the federal government this week that no claim for payment of a service rendered in the emergency department can be denied, in whole or in part, based solely on the final diagnosis.  This determination must be based on all pertinent documentation and be focused on the presenting symptoms — and must take into account that the legal standard regarding the decision to seek emergency services is based on whether a prudent person would reasonably consider the situation to be an emergency.  The Downcoding Provision has the exact opposite effect.

Read the full letter sent to Xavier Becerra at the U.S. Department of Health and Human Services and Chiquita Brooks-LaSure at CMS.