Source: American Academy of Family Physicians

In this episode of ‘Inside Family Medicine, guest host Vice President of Practice Advancement for the American Academy of Family Physicians (AAFP) Karen Johnson, PhD, talks with Tina Philip, DO, a solo family physician in Round Rock, TX, 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.

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