In 2021, the MDA’s two legislative priorities this year are down-coding of claims and provider credentialing clean-up legislation (specific to dentists), which we further explain below.
The term down-coding is used to describe a growing phenomenon, in which an insurance carrier modifies the procedure code originally submitted by the healthcare provider and reimburses the amount attributed to the new code in lieu of the originally billed code. In a 2020 MDA membership survey, 94 percent of dentists said they experience down-coding, with 100 percent of those stating it results in lower payment. Unfortunately, this practice is not limited to dentists and affects other healthcare providers, too. A recent analysis done by other large medical practices found up to 68 percent of their claims submitted to the three Medicaid MCOs (United Healthcare, Anthem or Homestate)—Missouri’s three largest health insurance carriers—were categorized by the insurers as “fraudulent”, resulting in the submitted code being changed to a code with a lower reimbursable rate or from a covered to a non-covered service code. When this occurs, the healthcare provider is forced to write off the difference and absorb the loss. The MDA is eager to work with other health care provider groups and associations across the state to address this growing problem.
The second priority issue for the MDA pertains to credentialing. This year, the Missouri General Assembly passed House Bill 1682, a bill designed to enforce prompt credentialing for healthcare providers. Most important, it requires a health insurance carrier’s credentialing decision to be issued within 60 days of receiving an application and prohibits a carrier from requiring a practitioner to be credentialed if the practitioner is working on behalf of a credentialed provider who is on FMLA leave. A prominent Missouri dental insurance carrier has not adhered to the new law, citing exemption based on their tax status. We believe that regardless of the type of corporation, an insurer of health benefits should be required to abide by this law.