IFM | Downcoding: How Payers Are Cutting Payments and What Family Physicians Can Do

Guest host Karen Johnson, PhD, VP of Practice Advancement for the AAFP, talks with Dr. Tina Philip, DO, a solo family physician in Round Rock, Texas, and AAFP CEO, Shawn Martin, about payer downcoding, where insurers reduce billed evaluation and management levels (e.g., 99214 to 99213), lowering payment and adding administrative burden. Dr. Philip describes how downcoding most often affects moderate-to-high complexity office visits and stresses physicians must monitor claims beyond denials by working with billing/coding staff to confirm expected reimbursement. Martin explains downcoding as an evolution of coding integrity programs amplified by AI-enabled scale and as a less visible cost-control approach than prior authorization, often with limited transparency and historically few appeals.

Topics By Timestamp

01:01 Why Family Medicine

02:32 What Downcoding Means

04:02 Why Payers Downcode

08:40 Spotting It in Practice

10:51 Who Should Investigate

12:07 AAFP Advocacy Efforts

15:17 Undercoding and Appeals

18:04 Tools and Next Steps

20:29 Final Thoughts

Additional Resources

Coding for Evaluation and Management Services: FAQs

Letter template for writing to payers about ending downcoding policies

The AAFP Advocates Against Payer Downcoding Policies and For Improved Primary Care Payment

AAFP urges feds to investigate downcoding as threat to primary care | Advocacy and Government

Cigna's downcoding policy gets pushback from physician groups | AAFP

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