Illinois legislators pass Transparency in Downcoding Act
The Illinois legislature recently passed Senate Bill (SB) 3114, the "Transparency in Downcoding Act," legislation supported by the Illinois State Medical Society (ISMS), and it is now waiting for the governor’s signature.
The legislation aims to address the use of automated downcoding programs being used by payers to reduce intensity levels and physician payment without justification or review of the patient’s medical record. Specifically, SB 3114 would:
- Prohibit a health insurer from using an automated process, system, or tool to downcode a claim
- Ensure that a physician will be notified when a claim has been downcoded and reimbursed at a lower level, including the clinical reason for downcoding
- Require health insurers to establish a clear and accessible process for disputing downcoded claims
- Prevent health insurers from using downcoding to discriminate against physicians who commonly treat patients with complex or chronic conditions
Once signed, Illinois will join Indiana and Virginia legislatures in addressing health insurer downcoding practices this year. However, more than a dozen states introduced bills this year, indicating the growing concerns and frustration among physicians, patients and advocates with this harmful payer practice.
The AMA has model legislation and other resources to assist medical societies in their downcoding efforts. Please contact [email protected] for more information.
