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Law Educator, Esq.
Law Educator, Esq., Attorney
Category: Legal
Satisfied Customers: 118788
Experience:  JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
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Is down coding by an insurance company illegal I send in a

Customer Question

Is down coding by an insurance company illegal
I send in a claim to an insurance company and they down code it by saying I didn't give satisfactory documentation for the code I used and they lower the code to a service less of a reimbursement and pay for the down coded code? In the state of Hawaii and California?
Submitted: 1 year ago.
Category: Legal
Expert:  Law Educator, Esq. replied 1 year ago.
Thank you for your question. I look forward to working with you to provide you the information you are seeking for educational purposes only.
The insurance company can change the code if the medical records for the date of service do not justify the code that you submitted. You can correct your records and resubmit to dispute the changed code. However, the legal right for down coding is based on the contract between insurance company and doctor. Most contracts will specify the basis on which payment is made (i.e. AMA CPT codes using some type of conversion factor to determine dollars paid). The contract will also specify who has the authority to review claims and delineate appeal processes for disagreements.
So you need to refer to your contract and get your appeal filed with your corrected justifications.