CONTACT YOUR STATE LEGISLATORS TO SUPPORT AND SPONSOR 
SENATE BILL 3114 & HOUSE BILL 4735: THE TRANSPARENCY IN DOWNCODING ACT

Please contact your state legislators today and urge them to vote YES and sign on as a sponsor to Senate Bill 3114 & House Bill 4735: The Transparency in Downcoding Act. 

Senate Bill 3114 (SB 3114) and House Bill 4735 (HB 4735) treats downcoding as an adverse determination of a medical claim and happens when a health insurer reduces the level of service submitted on a claim based on algorithms or standardized payment policies, resulting in lower payment for the actual time and treatment provided by the physician.

The insurance industry is arguing that physicians intentionally and fraudulently “upcode” claims to make more money.  Let your legislators know that is not true.   

SB 3114 and HB 4735 places much needed guardrails on the practice of downcoding by health insurers to ensure that a payer’s decision to downcode a claim is transparent, made based on an actual review of clinical documentation, and includes opportunities for physician appeal. SB 3114/HB 4735:

• Prohibits the use of automatic downcoding through the use of tools and processes including but not limited to artificial intelligence, or the association of payment levels with specific diagnosis codes.
• Requires downcoding determinations to be made by a licensed physician based on a documented review of the information supporting the level of billed service. The reviewing physician must be experienced in managing the medical condition or disease for which the services are being claimed.
• Requires insurers to clearly notify physicians on their remittance advice when a claim has been downcoded and paid at a lower level. Notification must include the clinical reason for downcoding.
• Requires insurers to establish a clear and accessible process for appealing downcoded claims and ensure that appeals are reviewed by a licensed physician with experience with the medical condition being managed and the services being appealed.
• Ensures the insurers cannot use downcoding to discriminate against physicians who commonly treat patients with complex or chronic conditions. SB 3114/HB 4735 provides the Department of Insurance the authority to issue penalties to insurers who demonstrate patterns of discrimination.

Failure to pay physician practices appropriately for the time and effort they spend treating complex patients undermines the viability of physician practices and may ultimately result in decisions that negatively impact patient access to care, such as reducing time spent with individual patients, reluctance to treat patients with complex needs, and even practice closures. Help protect access to care and keep physician practices open by supporting Senate Bill 3114 and House Bill 4735!

CONTACT YOUR STATE LEGISLATORS TO VOTE YES ON SB 3114 & HB 4735!