Grant
241 posts
@bcbstx Stop letting algorithms override physicians. Your automated E/M downcoding policy underpays providers without reviewing medical records, hurting practices and patient care. We've filed complaints with @TXInsurance and are pursuing legal action #TexasHealthcare
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Grant retweetledi
Downcoding without altering the remittance code is a specific kind of fraud on the adjudication layer, not just aggressive contracting, because it severs the only signal providers have to detect and appeal the underpayment.
And that severance is the point.
If the remittance still shows 99214 but the math reflects 99213, the provider's billing software flags nothing, the AR team sees no denial to work, and the underpayment sits invisible until someone runs a manual payment variance analysis, which most independent practices lack the staff to do systematically. The mechanism only works because payers and providers are each running separate interpretations of the same contract with no shared ground truth to arbitrate against. That gap, the one between what the contract says and what either party's system actually computed, is exactly where this kind of manipulation hides. What the exchange model I've been writing about would change is not the payer's incentive to do this, but the structural possibility of it: if a neutral third party holds the executable contract and settles the claim against it with binding finality, the payment is the payment, and a remittance that obscures the calculation becomes detectable on the first transaction rather than the hundredth. The moat for that infrastructure is not the AI that reads contracts, it is the canonical logic that both sides have already validated and cannot later quietly reinterpret.
onhealthcare.tech/p/the-case-for…
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Grant retweetledi
@cdemoormd @BCBSTX Oh, they would be in so much trouble if they were to change the CPT code in an electronic transaction. @DrAlexUrology can share facts on how much trouble. So, they found backdoor thru “remit” codes. Not for long. BUCA does not value the work u do. Tell all ur patients. @mcuban
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Grant retweetledi
Cigna has been changing codes for a while on remittance but at least it’s not a blanket every single claim and it gets caught in the posting system so easy to flag for appeal. BCBSTX is bypassing billing system safguards by simply increasing adjustments without true explanation and it seems across the board. They aren’t new to using codes to bypass billing systems… they’ve been using PR-45 to shift balance bills to patients for a decade or more- and it helps them make reports look pretty for their ASO clients- isn’t that right fellas? 🧐
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Grant retweetledi
Just starting to see the @BCBSTX AI auto downcoding of literally every single claim. Not based on records, not based on any reason except to give the last fatal blow to independent physicians. Meanwhile- they are paying exorbitant amounts to major hospital systems for massive facility fees. Independent physicians ARE already CHEAPER and that’s why they hate us! There is zero way this can be allowed to continue! Appealing every claim and sending every single instance to TDI! This will obliterate the small amount of what is left of the independent practice of medicine in Texas! @KenPaxtonTX @TexasTDI @texmed This must be stopped!
#insurancefail
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Grant retweetledi
Wanna know how they are doing it? @bcbstx is taking any 99204/99214 or 99205/99215 from in-network independent physicians and auto downcoding to a 99203/99213.
But they are being hella sneaky and not actually changing the code on the remittance advice.
They are using the following- “CO - Contractual Obligations
186 - Level of care change adjustment
N610 - Alert: Payment based on an appropriate level of care.”
Payment changes, adjustments change but not the actual code in remittance. CO-186 seems to be their little AI bot tool to downcode no matter what. They aren’t even paying attention to diagnosis codes or obvious complexity based on diagnostics etc.
So sneaky in fact- physicians may not even realize what has happened to them until it is too late.
Got a new diagnosis of metastatic cancer? According to @BCBSTX - worth a 10 minute visit
Pass out at home and go to your doc or urgent care instead of the ER? According to BCBS- worth a 10 minute visit.
Good news for providers- you can appeal/dispute this absolute trash with the staff you can’t afford to pay! Or better yet- you can get tied up in litigation for years. 🤬
First they came for the physician owned hospitals, then they came for the freestanding ERs, next they went after all facility based physicians, and finally they went after independent primary care and specialists. This IS the attempt at the final blow to Texas physicians. Comply or be assimilated into employment!
#insurancefail
Carrie de Moor@cdemoormd
Just starting to see the @BCBSTX AI auto downcoding of literally every single claim. Not based on records, not based on any reason except to give the last fatal blow to independent physicians. Meanwhile- they are paying exorbitant amounts to major hospital systems for massive facility fees. Independent physicians ARE already CHEAPER and that’s why they hate us! There is zero way this can be allowed to continue! Appealing every claim and sending every single instance to TDI! This will obliterate the small amount of what is left of the independent practice of medicine in Texas! @KenPaxtonTX @TexasTDI @texmed This must be stopped! #insurancefail
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@bcbstx Stop letting algorithms override physicians. Your automated E/M downcoding policy underpays providers without reviewing medical records, hurting independent practices and patient care. We've filed complaints with @TXInsurance and are pursuing legal action#TexasHealthcare
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Hey @bcbstx, algorithms aren't doctors. Stop automatically downcoding E/M claims without reviewing medical records. Every wrongful cut takes resources away from patient care. Texas providers deserve fair reimbursement. #Healthcare #Texas
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@BCBSTX @bcbstx Stop letting algorithms override physicians. Your automated E/M downcoding policy underpays providers without reviewing medical records, hurting independent practices and patient care. We've filed complaints with @TXInsurance and are pursuing legal action #TexasHealthcare
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Grant retweetledi
Ever wonder why we got so many Air Jordan 1 OG Low Travis Scott’s in such a short amount of time!? Answers really simple actually!! To think this all started with a bit of convincing and conversation with RJ because he didn’t want a low!
The answer is that the AJ1 OG Low TS was its own line. Self contained and done in its own shape and fit. Morphed from the 2015 cut, but different from the OG low Sb cut yall got for the last few years until recently when they updated it.
Whether or not it continues on, it’s been solidified as one of the most significant pieces in history and shifted the look and hype around OG lows! Salute to @trvisXX and thank you Reggie cause without you we wouldn’t be here talking about this particular series 🫡.
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