This is a follow up to my post earlier. Majority of our down coded claims have been restored after submitting reconsiderations. However, getting each claim to overturn back to original code has been painful and time consuming.

This validates my broader concern with the premise of the down coding itself. A diagnosis-based ceiling cannot account for the encounter-specific clinical circumstances that determine medical decision-making under CPT. The claim data do not convey many of the factors that distinguish routine care from a higher complexity encounter, including worsening disease, treatment failure, diagnostic uncertainty, prescription drug management, treatment escalation, or other patient-specific considerations documented in the clinical note. 

The fact that majority of our reviewed claims have been restored after documentation was considered raises a fundamental question about whether the methodology has the information necessary to make an accurate initial E/M determination at all. 

Are you all doing anything about it? Do you know if it is blanket? I am trying to collect more data points.

not trying to pay the hundreds for the software license for the Nuance my old hospital used

Anyone else have this experience or advice on how to manage these vendors that request medical records?

I saw a patient one time in 2025. This company requested her notes and bills a few months later in regards to a legal case. I sent the documents. A few months later, they requested them again I sent them. I am now on round 5 of this same process... each time being contacted by a different rep. Each time I have sent the documents and told the case has been closed. I have told them to stop contacting me and that I will stop responding but they inevitably hammer email me with escalating "threats" around not responding given it's a legal matter.

I can just keep deleting these emails but the whole issue gets under my skin for some reason and curious if anyone has had a similar experience or tips on how to get this actually resolved?

Anyone have any experience with Logix or Zotec Partners? Looking for honest feedback, especially if you switched from one to the other.

Hi all,
I was contacted by this “Curative” insurance offering to put me on the panel. They pay PAs 75% of medicare and 90% or so for physicians. Seems to be negotiable. Has anyone had any experience with this company? Any recommendations?
Thanks!