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TMA, Murfreesboro clinic: downcoding has forced extra staff and long appeals with high overturn rates
Summary
The Tennessee Medical Association and a Murfreesboro practice told the committee that automated claim-edit programs have led to thousands of downcoded claims, required new staff to manage appeals, and produced high overturn rates in the practices' favor, creating cash-flow and administrative problems for small clinics.
Julie Griffin of the Tennessee Medical Association told the committee that claims-processing programs are "a nightmare for medical practices," arguing that automated edits and downcoding have created misprocessed and delayed claims statewide.
"One medical practice in West Tennessee ... had more than 800 downcoded claims," Griffin said, and she introduced Meredith May, revenue cycle manager for Murfreesboro Medical Clinic, to describe her practice's experience. May told the committee that since April of last year her clinic had about 4,000 downcoded claims, had hired two additional staff to manage reconsiderations, and reported a roughly 97% overturn rate on reconsidered appeals in the clinic's favor.
"We are in the process of reconsidering them," May said. "For the ones that we have received that reconsideration ... approximately 20 to 30 minutes per reconsideration, there's been a 97% overturn rate in our favor, which supports our coding is accurate." She added that the overturns lead to rebilling patients for differences and increased patient call volume to explain new bills.
TMA witnesses framed the problem as an administrative burden on small medical practices and urged the committee to consider provider impacts, appeals costs, and potential refinements to payer audit processes.
