Key takeaways from this episode

• At least two payers are now automatically downcoding level 4 and level 5 E/M visits to level 3 without reviewing records, and Cigna has announced it will start doing so routinely on October 1. The downcodes arrive on the EOB with no warning, as an adjustment with a "documentation does not support" reason or a similar CARC or remark code, and PRS expects Medicare Advantage and commercial plans, but not traditional Medicare, to follow.
• Appeal every non-substantive downcode with the record. Groups that appealed with documentation have had claims restored to the level billed, and a couple of groups have been removed from the payers' automatic downcoding programs entirely.
• Check your EOBs and adjustment codes, not just your payer bulletins. Auto-posting reads these downcodes as logical adjustments; if your system lumps everything into contractual adjustment instead of capturing the specific adjustment codes, you will not find them. Set up a protocol for who reviews the notes and how the appeals go out.
• Appeal windows differ by payer, and United's is the tightest. UnitedHealthcare gives you 60 days to start an appeal; other payers allow 90 days, six months or a year; Medicare and many Blues plans allow a year.
• Quickest way to see whether you are affected: pull your Humana level 4 and level 5 visits. The mass downcoding first appeared in late April or early May 2025.
• UnitedHealthcare is not exiting Medicare Advantage. The roughly 600,000 members reported in the news are in specific geographic areas, often where United subcontracted with local provider groups, that United has elected not to continue; Medicare Advantage remains a major part of its portfolio.
• If a Medicare Advantage plan is dropped in your area, flag those patients now. Notification comes by mass email or website post rather than a phone call, so at the next visit ask what the patient is switching to (traditional Medicare or another Advantage plan) and update their insurance information.
• Assign someone to subscribe to every payer's newsletters and bulletins, and transfer those accounts when staff turn over. Expect more utilization review, denials and "games" as payers respond to earnings pressure and falling stock prices.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 254, recorded August 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Automatic downcoding is on the rise

[00:00] Scott Painter: On this episode: downcoding is on the rise, and what you need to know. Also, is UnitedHealthcare getting out of Medicare Advantage plans? Stay tuned. Welcome to episode 254 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. The first subject we want to talk about is downcoding. Mark was just sharing with Ray and me that downcoding is expanding and there's more downcoding going on. Mark, what are you seeing, and what can everybody do?

Mark Painter: As we know, we have had a couple of payers out there that have decided, without review of records, to downcode: to change your E/Ms from a four or a five down to a three without announcement, without any real formal investigation. As we've updated you in the past, we've been appealing those. They slipped through a lot of the auto-posters as an adjustment code with a reason of "documentation not supporting," or a couple of other CARC or remark codes that were included in the EOB. So they just showed up on the EOB without any warning whatsoever.

This is the first part of this. We were able to go back through a number of these denied claims, appealing them with records, to get them restored to their appropriate coding based on the documentation. And a couple of these groups have now been removed from the automatic downcoding program from these payers. So not only is it smart to appeal these things, because you're potentially losing money on each one of these non-substantive downcodes, but you are going to alleviate some of the work that's required. But boy, it's a lift, because with larger groups, the number of downcodes was significant.

Then we also had an announcement from Cigna that they are going to start doing this routinely as of October 1. This was an official announcement. They did put out in their document that there is a way to get off of these automatic downcodes by submitting documentation in an appeal form to actually get these readjusted to where they should be. It is advisable to take the time to review each one of those notes before they go back out the door to the payer. Obviously, it depends a little bit on your confidence in your physicians and their coding as to how detailed those reviews need to be. And it is a volume of work that needs to be done by your AR team. So coming up with a systematic approach for how to review, who does the review, and how those appeals get submitted is something you want to set up as a protocol, as we're seeing this practice by the insurance companies expand to different payers and different regions of the country.

So keep an eye on your payer bulletins, for one thing, to see what's happening. But importantly, keep an eye on your EOBs. If you're getting payments that are lower than expected, or your adjustments are going up, it's worth going back into the records on the EOB side to see if some of these adjustments the carriers are making are actually slipping through your team, because they come through as logical adjustments. Based on some of those auto-posting reads, they've just come up as adjustments, like a contractual adjustment. And if you're a group that doesn't capture, or your system can't capture, those specific adjustment codes and everything goes to contractual adjustment, you're not going to be able to find these things as easily.

So there are a couple of things I think we've learned as we've gone through this. Number one, one of the things we've preached for years is pay attention to the details. Get your system set up appropriately, then your procedures and your protocols set up, so that things like this don't slip through and build up on you. Some of the groups we had, we noticed this right away, but they still built up on us because of the volume of the denials that came through. That then requires a protocol or a process to grab those notes, quickly review them and resubmit them, to get those automatic downcode blocks for your particular group removed as fast as you can, based on your accurate coding.

And of course, it all translates back to the very beginning. There are a lot of physicians out there, and a lot of systems out there, that are not giving you accurate codes, or your documentation doesn't support the codes you're using, which ultimately the payers are counting on. They're counting on those two factors: number one, you missed it, so you didn't actually run the appeal; and number two, your documentation and your coding in the very beginning weren't accurate. So you have to make sure all of those things flow into place, and the more you pay attention up front to everything being correct, the lighter the load when payers pull some of these shenanigans. Across the board, it affects everybody in the practice: how they interact with the electronic medical record, your chart documentation, your coding, your submission, your posting. You've got to have those protocols, procedures, reviews and processes in place for these crazy games the payers are playing.

How many payers are doing this, and how far back can you appeal

Scott: I've got a couple of questions, but Ray, do you have any comments or questions before I go?

Dr. Ray Painter: I tell you, the person that came up with this, if you are working for the payer, was a genius, because now they put all the work on the office to do it instead of auditing records and denying. They've turned it around. It's not fair, but they can do that. Now, Mark, we've seen in the past that when one payer is successful at something like this, all of them adopt it. So how many payers are you seeing doing this now?

Mark: In broad spectrum, we've got at least two payers that are doing it, but we certainly would expect that others will follow suit, or potentially follow suit. We don't expect Medicare to do this, but we do expect to see this with Medicare Advantage and commercial plans.

[08:00] Scott: All right. Anything else, Ray? No. Okay. I have two questions for you. One is, when did this actually start? And can somebody who has missed this and hasn't been paying attention go back and submit these appeals, and for how long?

Mark: I believe, if I remember correctly, it was either late April or early May that we first saw this pop up, but that's going from the top of my head. So somewhere in that timeframe, April, May, is when we first saw this happening. Now, it had been scattered throughout. It's not like it hadn't happened in the past. We've definitely had a local Blue Cross and Blue Shield or a local smaller payer downcoding different practices over time, but usually with chart reviews ahead of time and a finding that they weren't doing a good job. This mass denial stuff, that was the April, May side. So it's not like it hasn't existed in the past. It has; it's just not been as widespread.

As far as the appeals process and how far you can go back, unfortunately my answer there is, it depends. Different payers have different statutes of limitations on when you can react to a denial. United has a fairly strict protocol: you've got 60 days to start an appeal, and if you haven't touched it in those 60 days, they won't consider it. Some of your other payers have a little bit longer window: 90 days, six months, a year. So it really is dependent on the payer and what your contract is with that particular payer. Medicare's a year. A lot of your Blues plans are a year. Other payers vary a little bit. Some follow Medicare, some are a little bit stricter, but United really has the tightest deadlines that I know of, at 60.

The quickest way to check whether you are being downcoded

[10:00] Scott: So let's say somebody's listening, one of our audience members, and this is the first they're hearing about it. They're a urologist and they want to see if they're being downcoded. What is the very quickest way for them to look at that? If you were that urologist and you wanted to see, really quickly, "Am I a part of this?", what payer would you look at and what kind of claim would you look at?

Mark: I'd look at Humana, and I'd look at my level fours as my starting point, and my level fives for that matter.

Scott: Not a particular visit, just a level four, level five.

Mark: Yes.

Scott: Okay. That's all the questions I had on that. Any more comments or questions on downcoding?

[11:00] Ray: Just to emphasize what Mark said, it really pays to look at your EOB, and you should appeal everything that is unfairly denied, because payers are in this to make money. We've seen this over the years, time and time again: when they find a practice that's not paying attention, you see more and more denials. So it's important to be sure that part of your team is active and appealing everything that you are unfairly denied on.

Scott: Indeed. And I'll echo what Mark said. What we're seeing is that the documentation is so important. Not only do you need your clinical documentation, which urologists and APPs have had a lot of practice doing, urologists a lot more so than APPs, but the clinical documentation, no matter how good it is, doesn't necessarily have all the reimbursement documentation you need in order to get paid accurately. So you need to know what those magic words are to include in your clinical documentation. That's a very important piece.

Is UnitedHealthcare getting out of Medicare Advantage?

Scott: Okay, let's move on to the second thing. What about the discussion, or I guess rumor, that UnitedHealthcare is getting out of the Medicare Advantage programs? Is there any truth to that? What have you heard, Mark?

Mark: We had a couple of folks who emailed us that UnitedHealthcare was dropping Medicare Advantage; in particular, this was 600,000 people, and this was picked up in news stories across the board. Of course, everybody thought, wow, if they're doing that, how far are they going? Is this a widespread move, or is something else happening? As it turns out, the United system has decided to cancel certain areas, particularly where they had some subcontracting with individual payer groups or provider groups within a particular geographic area. So there are some drops, but in the end, Medicare Advantage is a big part of UnitedHealthcare's portfolio, so we do not see this as a systemic issue. We certainly see that there are areas where UnitedHealthcare was not doing well in a particular geographic region, and they have elected not to go forward with that.

I can understand the concern, certainly, when you look at something like this occurring in a particular area. You've got a number of members who are now rolling into a new year who may have had a Medicare Advantage plan and are now going to have to find a different avenue, either going back into traditional Medicare or moving to another Medicare Advantage plan. So if you get a notification like this, you definitely want to flag those patients so that the next time they come in, you're talking to them about what they're going to do, and you're getting updated insurance information as they migrate to a different type of coverage. Under Medicare, they can always go back into traditional Medicare, but they may choose to cycle through and find another Medicare Advantage plan to maintain their coverage and their Part D benefits, which oftentimes are the real hook to bring people into Medicare Advantage plans.

Notification requirements and watching payer bulletins

Scott: This may be a fact you can't pull off the top of your head, but do you know if there's a requirement for notifying providers prior to canceling a Medicare Advantage plan?

Mark: Typically they do, but they don't do it like an individual phone call. It'll be either a mass email or a post on their website. So there's going to be notification that those plans are dropping, to both the patients and to the physician practices who have contracts with that particular payer. And this isn't the first time somebody's dropped out of Medicare Advantage, or dropped out of the insurance market through bankruptcy or other things. So it's not like it's a foreign concept. But it is something that we know is coming, and we did get some alarming pieces, because that's a big chunk of people, that 600,000 that was dropped in a particular area. That's a big chunk of people to throw back out into the market, and it does represent a business move, I think, by UnitedHealthcare to protect their own financial bottom line. So they're putting that notification out now, and everybody needs to start prepping to make the switch.

Scott: All right. So your recommendation is to keep your eyes open for possible Medicare Advantage cancellations, not only with United but with any other Medicare Advantage plans.

[17:00] Mark: You want to keep an eye on all your carriers and your payer bulletins to find out if there are any big announcements, in addition to the little ones, like whether or not they're covering a particular disease state or any of those things. Those are the things we always encourage you to monitor, and you should definitely have somebody in the practice who is subscribing to your payer newsletters to catch that information. And make sure that if you've had some turnover or changes in your personnel, those emails or those accounts that are signed up are transferred to the appropriate people within your practice, so you don't miss big announcements like this.

Sponsor and the PRS Coding and Reimbursement Hub

Scott: Ray, any questions or comments? No. All right. Well, we'll wrap this episode up here. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prsnetwork for specials for our listening audience. Also, I want to remind you that the PRS Coding and Reimbursement Hub is up and running. If you go to prsnetwork.com/urologyhub, you can see information on urology categories and specific pharmaceuticals and devices, and we're adding more and more to those each month. So please check that out. There's information on how to code for that particular urology category or that particular device or pharmaceutical, and it's always expanding. All right, let's get some final thoughts. Mark, what's your final thought today?

Final thoughts: payer pressures and the Medicare Advantage market

[19:00] Mark: Today's episode really surrounded payers and payer activities, which is often a topic of our conversations: keeping an eye on what the payers are doing and how they're reacting to these changes that are either happening or have happened. We saw that UnitedHealthcare stock was tanking for a number of things. They've had a few things hit them all in a row, including the assassination of their CEO, which did affect their stock price. Then you also had some reported earnings where some of their plans actually reported significant losses, well above their projections. And then we've got the back and forth with the administration relative to Medicare Advantage plans, where they took away their money and then gave them some of that back. So those are market effects that the payer is going to have to react to, and you'll probably see some more activity around the Medicare Advantage market as we continue to watch some of these changes in the federal government and how they're approaching healthcare and benefits within the U.S. So you'll want to keep an eye on that.

And then the secondary piece is, with those pressures, and ultimately payers who have enjoyed very nice profits for several years now suffering a few changes that are cutting into their profits, how they react to those is most likely going to be increased utilization review and increased games like this. They're going to try and look for ways they can save money across the board, and that'll most likely include higher denials and more of a hassle factor on getting things into and through the system, at the same time that they're pledging to make prior authorizations easier. So it's going to be a topsy-turvy world over the next several years as we watch the payers react to the downward pressure on overall spending in healthcare.

Scott: Ray, final thoughts?

Ray: A question. Rumor had it that Trump and his administration were very much pro Medicare Advantage, and we've known that Medicare Advantage has had a price advantage in many ways. Has that decreased? Is that price advantage, that they get paid more than Medicare, changing?

Mark: There were some changes early in the year, yes. And I would go so far as to say that it was a stated goal of the Trump administration to privatize more things, and specifically what they could do to focus on Medicare Advantage plans. But they wanted some cost savings in there, and there was a move initially to take some of the revenue advantages out. They did go back in and restore some of that money, so that brought the payers back to the table and their interest in Medicare. But there are other things the payers are doing with risk-based plans, and some of these areas around the country aren't working as well. The utilization is higher. Different things are affecting that overall profitability within Medicare. So it's not just top-down pricing, it's bottom-up in cost as well. All of those things are creating pressure that is going to require reaction, and of course, not the least of which is, where is everyone's stock? That's the ultimate measure. If the stock's going down, chances are those payers are going to have to make some changes to get the stock back up, because in the end that's who they answer to in their overall reporting. Even if the board and the C-suite make the decisions, their long-term pressure comes from the stock price.

Ray: So we'll probably see more things like automatic downcoding. Beware.

Scott: That's for sure. A lot of big changes coming up in 2026, and a lot of changes happening now. If you want to stay up to date and prepare your practice, we encourage you to join us at the Urology Advanced Coding and Reimbursement Seminar, either in Las Vegas in December or in New Orleans in January. We'd love to have you there, to be a part of the conversation and see if we can't figure this out and make practices successful in 2026 and beyond. That's all we have for today's episode. Thank you all for listening. Take us out, Ray.

Ray: Happy coding.

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