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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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