Medical billing and revenue cycle management
Payers stopped denying your level 4 and level 5 visits. They pay them as a level 3 instead. No denial code, no rejection, no task for anyone to work. The claim shows as paid and the deposit is just smaller.
Twenty minutes. If there is no reason to change, we will tell you that.
The HHS Office of Inspector General audited a random sample of Medicare evaluation and management claims and found 15% were downcoded, costing physicians $1,762,426,570 in a single year. That is report OEI-04-10-00181, and it is 2010 data, which predates the 2021 E/M rewrite. It establishes the scale of the mechanism, not a current-year estimate.
Aetna began downcoding E/M claims around the end of March 2025, with no advance notice.
Cigna's R49 policy, effective October 2025, drops 99204, 99205, 99214, 99215, 99244 and 99245 by one level when the primary diagnosis does not match, without reviewing the chart. Cigna's own examples of triggering diagnoses were earache and sore throat.
Maryland fined Cigna $80,000 in March 2026 and ordered it stopped. California paused it. Indiana legislated against it.
Pull your last 25 claims billed as 99214. On each remittance, confirm it was paid as 99214, not just that it was paid. Any mismatch is a downcode, and it never appeared in your denial report because it was never a denial.
The basics, since you will check anyway
A downcode is only one of them. None produces an event anyone works.
The code you billed and the code they processed are different. Nothing flags it, because the claim paid.
The shortfall arrives as CO-45 and auto-posts as a contractual adjustment. The balance zeroes itself.
The note exists, the charge was never built, so no claim was ever submitted to deny.
A real event that generated a real task, which nobody worked, and which no report totals for you.
A client kept running long on follow-up visits. The schedule said one thing, the claim numbers said another, and the two never lined up. Our team asked about the gap.
The practice had been providing a service they did not know was covered. It was documented in the notes every time. It had never been submitted. We filed retroactively and it kept paying going forward. The level of care they wanted to provide stopped being a time cost, and growth became an option.
Step one
You check it yourself. The self-check above takes one report and about ten minutes. You do not need us for that part and you do not have to tell us what you found.
Step two
Twenty minutes on the phone. You tell us what you found and what you run on. We tell you what we would expect to find underneath it and what it takes to fix.
Step three
If you move, payer contract renegotiation is part of onboarding, at no separate fee. Rates set back when the practice was smaller are usually the second thing we find.
Nobody outside your practice can answer these. No report inside it puts them in front of you either. Most owners can answer two.
Of your last twenty-five level-four visits, how many were paid as level four, not just paid?
If an NP or PA sees your established patients, are those visits paid at 100 percent or at 85?
Where does your level distribution sit against your specialty's national distribution?
When a payer pays a code down a level, what in your system tells you it happened?
Has anyone appealed a downcoded claim on your behalf in the last year?
For one payer and one code, are all of your allowed amounts the same number?
If you can answer all six, your billing is in better shape than most practices and you probably do not need us. If you cannot answer four of them, that is not a competence problem. No report in your system was ever built to show you these numbers.