The Illinois State Medical Society (ISMS) is focusing on the issue of automatic downcoding by health insurers, a practice where insurance companies use third-party vendors and artificial intelligence tools to reduce payment levels for medical claims. This occurs even when the documentation supports a higher level of service.
ISMS has identified restricting downcoding as one of its top legislative priorities in Illinois. The organization argues that this practice threatens physician reimbursement and could impact the financial stability of some medical practices in the state.
Recently, two bills—Senate Bill 3114 and House Bill 4735—were introduced in Springfield with ISMS’s support. These bills propose several measures:
– Prohibiting health insurers from using automated processes or systems to downcode claims.
– Requiring that only physicians with the same or similar specialty as the treating physician can make decisions about downcoding.
– Establishing a simpler appeals process for disputed claims.
– Mandating that appeals be reviewed by a different physician, also of the same or similar specialty.
– Ensuring transparency regarding clinical justification when claims are downcoded.
ISMS is gathering data to show lawmakers how widespread downcoding is and how it affects the financial health of medical practices. The organization is encouraging physicians to participate in a brief survey to provide more information on this issue.
“Our efforts on downcoding are supported through a grant from the American Medical Association (AMA). We thank the AMA for its backing,” ISMS stated.
For further questions, ISMS directs inquiries to Erin O’Brien, Senior Vice President of State Legislative Affairs.
