Amendment #25 to S3141

Protecting access for patients with chronic or complex conditions and downcoding transparency

Mr. LeBoeuf of Worcester moves to amend the bill by inserting after section 34 the following section:

"SECTION 34A. Chapter 176O of the General Laws is hereby further amended by inserting after section 12C the following section:-

Section 12D. (a) As used in this section, the following word shall, unless the context clearly requires otherwise, have the following meaning

"Downcoding," the unilateral substitution by a carrier of an evaluation and management service code or other service code submitted on a claim by a health care provider, or the unilateral reduction by a carrier of the level of such a code, that results in a payment lower than the amount that would have been payable under the code as submitted; provided, however, that "downcoding" shall not include: (i) the correction of a claim on which a provider submitted 2 or more codes for services that are required to be reported under a single code pursuant to federal or state coding or program integrity requirements; or (ii) a change to a code that the provider requested or agreed to.

(b) A carrier or utilization review organization shall not use artificial intelligence, an algorithm or other automated process to downcode a claim without evaluation of the information submitted by the billing health care provider. A carrier or utilization review organization may use an automated process to identify claims that may warrant downcoding; provided, however, that a certified professional medical coder or a licensed health care provider shall make or review each downcoding determination and shall consider the information submitted by the provider on the claim.

(c) A carrier shall not downcode a claim based solely on the diagnosis codes reported.

(d) Upon downcoding a claim, a carrier or utilization review organization shall notify the billing health care provider in writing and shall include: (i) the reason for the downcoding, including the clinical information and coding guidance relied upon; (ii) the original and revised service codes and payment amounts; and (iii) the process for disputing the determination.

(e) The commissioner shall establish by regulation a process for a health care provider to dispute a downcoding determination, which shall afford the provider a reasonable period to file a dispute and shall require review by a licensed healthcare provider who was not involved in the original determination. This subsection shall not limit any other right of a provider or insured to appeal an adverse determination under this chapter or other applicable law.

(f) A carrier or utilization review organization shall not use downcoding to target or discriminate against health care providers who routinely treat patients with complex or chronic conditions.

(g) A carrier or utilization review organization shall be responsible for compliance with this section by any person to whom it delegates a function related to downcoding.”.

Additional co-sponsor(s) added to Amendment #25 to S3141

Protecting access for patients with chronic or complex conditions and downcoding transparency