AMA strengthens opposition to payer downcoding practices

ORLANDO - Physician and medical student policymakers at the American Medical Association (AMA) House of Delegates voted to strengthen medicine's opposition to insurer downcoding schemes that wrongly reduce payment for physician services and can threaten patient access to care.

Under the new policy, the AMA will work in collaboration with other physician organizations to strengthen ongoing advocacy against unilateral payer downcoding and help physicians understand new legislative protections, report health plan noncompliance to regulators and challenge inappropriate payment reductions.

"Physicians should not have to fight insurers to be paid accurately for the care they provide," said AMA Board Member Michael Suk, MD, JD, MPH, MBA. "Today's action builds on the AMA's ongoing advocacy to stop unfair insurer payment practices and ensure physicians are paid accurately for the care they provide to patients. We will continue pursuing legislative, regulatory and legal solutions that hold insurers accountable and protect patients' access to care."

Delegates also directed the AMA to develop and regularly update educational resources to help physicians document services appropriately, appeal unjustified downcoding and report inappropriate payer conduct through regulatory and AMA advocacy channels.

Payer downcoding programs can automatically reduce the level of service reported by physicians, sometimes using algorithms or other automated tools without reviewing documented medical services in the patient's medical record. Such practices can increase administrative and financial burdens on medical practices, undermine transparency in claims processing and jeopardize patient access to care.

The AMA supports legislative guardrails that prohibit automatic downcoding without clinical record review, require clear notice and explanations when claims are downcoded, and establish meaningful appeal processes.