Key takeaways from this episode

• Automatic downcoding of level 4 and 5 E/M visits can hide inside "paid" remits, so payment posting alone will not catch it. One payer sent roughly 400 downcodes in a week and a half; the remits adjusted each claim to a zero balance or to the patient/secondary balance, and it was the AR team working the aging, not the posters, who found it.
• Run a quick check of 99214 and 99215 reimbursement by payer against the Medicare allowable. If every contract other than Medicaid pays at or above Medicare, any level 4 or 5 paying below the Medicare rate is a red flag for downcoding that the remit and posting process missed.
• Watch for CO45 contractual adjustments with zero payment and no patient responsibility. Multiple Blue plans are processing claims as 100 percent write-offs that look "paid"; payers call it a system glitch and send the claim back through, so pull a monthly 100 percent write-off report and audit those charges.
• Appeal downcodes with the note attached and a plain statement of the level billed, and cap the time spent. PRS works downcodes two hours a day so other AR is not neglected; appeals must go in within the payer's window (as short as 45 days) while payers take 30 to 180 days to repay the $33 to $50 difference, and notes are reviewed before submission so a batch of level 3 notes does not increase the pulls.
• Ask your provider rep to remove you from automatic downcoding once you are winning appeals. Some payers have a metric (Humana around 70 percent) and will remove you, but they often put you back on 30 days to six months later, so keep monitoring.
• Send the complete record for everything on the claim, not just the E/M. Payers are paying the 99214 and then recouping other lines on the same claim (for example urodynamics) when the results were not included, and automatic recoups on remits are rising everywhere.
• Audit three remits per top payer (Blue Cross, UnitedHealthcare, Medicare) every month. Payers keep changing the remittance advice codes used for the same denial, so reading actual EOBs is the only way to confirm your system and your posters handled them correctly.
• Contract-variance tools work only with monthly maintenance, and AI posting needs a second layer of review. Load new CPT codes and payer carve-outs as they change, account for multiple-procedure discounts, and expect variance reports to break down about six months after maintenance stops.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 292, recorded June 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network, and guest Marianne Desciose, COO of PRS Managed Services.

Four hundred downcodes from one payer, hidden in "paid" remits

[00:00] Scott Painter: On this episode, downcoding, record requests, takebacks. We want to share evolving survival tactics that you can use. Stay tuned. Welcome to episode 292 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter, and we want to welcome back special guest Marianne Desciose. Marianne is the COO of PRS Managed Services and can share with us the tactics they're using to help combat some of these things. Thank you, Marianne, for joining us, and welcome back.

[00:38] Marianne Desciose: Thank you for having me.

[00:39] Scott: All right, Mark, I'm going to turn it over to you to introduce this. We want to hear what you and Marianne are dealing with on a day-to-day basis.

[00:48] Mark Painter: All right. Recently, and I mean over the last couple of months, we've been dealing with a significant increase in a lot of activities by the payers, including Medicare, that have made life a little difficult for us in the revenue cycle world, and I'm sure that others are seeing the same things. We've had a few discussions in our UPT group confirming that a lot of other folks are going through the same issues. So today I want to ask you about several things, and I'm going to start off with what really prompted me to bring you on today, which is the fact that we got, what, about 400 downcodes from one payer?

[01:35] Marianne: Correct. Just in the past week and a half.

[01:39] Mark: A week and a half. And the process that we're going through to get these things back out the door, let's start with how we identify this, because as you told me, this was not something that was obvious in the automatic posting of the claims.

[02:04] Marianne: Correct. We actually had our regular weekly call with my team, and we were discussing why denials had increased in the account, and we were reviewing those. From one payer, we received hundreds of downcodes from level fours and level fives, automatic downcoding. They weren't identified through our payment posting, because when the remit posted, it actually adjusted the claim to a zero balance, or to the balance that was supposed to go to the secondary and/or patient. Therefore, with the processes we have in place with verification, our payment posters did not catch it, but our team lead and AR team caught it because they were running through the AR and had seen items that were not paid correctly.

So we needed to go back to the payment posting team, who had a payment posting process in place to identify the remittance advice codes and put those over in denials. However, in this case, because it was adjusting them off, they balanced their remit, and they would not have known that these were paid incorrectly, because it actually took the balance off of the remit. So twofold, two issues: the increase of the downcoding, and also the fact that this would not have been caught had we not had steps in place for verifying even past our payment posting team, which was a blessing for us. However, other practices may not have those in place and may not find out until it's too late and past the appeal timely filing.

[03:49] Mark: So they just show up as essentially paid claims, with an adjustment that, if you post all the adjustments under contractual, you would never see. But now that we have a lot of the auto posters putting the payment posting reasons, or the CARCs and the RARCs, in there, we can search on those?

[04:12] Marianne: Correct. Ironically, in these cases too, there were several of them that were under a CO45, a contractual adjustment, which also would not have been something the payment posting team would have caught. In addition, more than 100 of those claims were CO45 with no payment at all, a 100 percent write-off.

A quick check any practice can run on E/M reimbursement

[04:29] Scott: I've got a question for you. If a urologist is listening to this and has a team they're very confident in with their RCM, what questions would you recommend they ask beyond the first question of "are we having downcoding?" Because it sounds like this took a little more detective work than the original downcoding was taking.

[04:58] Marianne: Correct. If I was looking at this from the urologist's, the provider's perspective in their clinic, there should be a process in place. I know these are more difficult processes, because there's not just a standard way to look at your reimbursement and compare it to your contracts. However, if you're just looking at your E/M codes compared to your contracts, and knowing what the level four at a Medicare level is supposed to pay, and if you know that in your practice all of your contracts besides Medicaid are over your Medicare allowable, then you should be able to at least run a quick report at a glance and look to see that your level fours and level fives are being paid at Medicare or above.

That would just be the first question I would ask, to make sure that's happening. If you see that, and that red flag goes up that says you have lower reimbursement than your Medicare allowable for a level four or level five, you would want to look further into that. That's what we ended up doing yesterday for a couple of hours, looking to see if this extended past what we had identified, so that we could actually identify with this payer that this hadn't been happening before last week. So if you're just doing a simple comparison, without a program that you run this through or a comparison in your system where you're adding your contracts and dumping out a report, if you look at the Medicare allowable for a 99214, run that through by payer and make sure you're getting that average reimbursement over Medicare's allowable, you can identify a problem pretty quickly if they're downcoding and the remit didn't catch it or your payment posting team didn't catch it.

[06:37] Mark: This is a case where you've got a few of the folks we work with that haven't supplied us with their contracts, and we haven't been able to use the automatic tools on contract payment monitoring. Do we find those work pretty well once they're up and running?

[06:57] Marianne: Yeah. As we've discussed, Mark, in numerous cases, the biggest piece of that is the maintenance. It is not one and done. The programs that are out there for contracts, or even EHR and PM systems that allow you to load those contracts in and do payment variance reports, the real big time crunch there is that you can't just load those contracts and be done with it. You have to do the maintenance. Every time there's a new CPT that's added, you've got to go and add those to your system. If you're having conversations with your payers and they're updating carve-outs for you, you have to go and maintain those programs. And you also have to understand the basics of RCM, so that when you're running those reports, you are not assuming they're underpaying, because many times you have multiple procedure discounts and you're not taking that into consideration. So they work really well; the maintenance is just there. When I say maintenance, it's usually a monthly maintenance. If you take that hour or two every month to maintain and make sure everything's good, you're going to keep that system up to date. If you do not do the maintenance, then usually about six months in, you're starting to see issues with the payer variance reports.

CO45 "stealth denials" that write off the whole claim

[08:04] Mark: All right, and then I want to loop back. You mentioned that some of the E/Ms came back with CO45 with a zero pay. What was that from?

[08:14] Marianne: Several months ago, we started identifying this with Blue payers. We were doing an on-site visit at one point, and we were seeing a CO45 with no payment on there, and we were asking what had been done with this. The practice actually didn't know this was happening. The CO45 was writing it off at a hundred percent. I have now seen this with multiple Blue payers, where they're processing it through, there's no payment, there's no patient responsibility, and it looks as if the claim is, in quotation marks, "paid," but actually there was no payment and no contractual adjustment, just a hundred percent adjustment.

Your systems identify CO45 as an adjustment reason, so you're processing through the remit, and it did a hundred percent write-off. What we were able to identify then is a double check on that: a report that runs every single month for our clients, making sure that your original charges, some people have a hundred percent write-off report. However, that's not foolproof. Basically, every month, where your charges and your adjustment are a hundred percent, you go and audit those charges. But this is happening, and the payers identify this as a glitch in their system. There's not one call I've had where they've said, "This was true." "We'll go ahead and send this claim back through processing" is usually what they say, but they say it's a glitch in their system. And I have seen it in every single client we have.

[09:41] Mark: Wow. That ain't good.

[09:43] Marianne: No. Luckily, many systems allow you to do 100 percent write-off reports. However, again, as we're diving more into AI and doing more automation, I'm reminding everybody that automation and AI is a tool, and you do still have to have a second layer of identifying, auditing, reviewing to make sure that the tools are actually working correctly.

Appealing the downcodes on the payer's clock

[10:07] Mark: All right, and then once we identify the downcodes, what's the process we're using to appeal those?

[10:15] Marianne: As Scott said at the beginning, this is ever-evolving. What we are doing at this time, because we cannot have our team spending 100 percent of their time on these hundreds of downcodes, is prioritizing time: two hours a day of working on the downcoding with the AR team, and then moving back over to the AR they are working in our denials for other payers. Anybody who has had to deal with this before knows we're under a time limit to get these appealed with these payers. However, the payers are not on any timeline to reprocess these claims. So we're spending that time doing an appeal, pulling the notes, stating, "This is a 99214. Please reprocess this claim. You paid it as a 99213. Here are the attached notes," sending those through, and it's anywhere from 30 to 180 days before those payers are reprocessing that additional payment of $33 to $50 that they underpaid on the original claim.

[11:14] Mark: And are we reviewing the E/Ms before they go?

[11:18] Marianne: Yes, in most cases we are. If a client has good coding, we know the providers are educated by us and knowledgeable in the process, or the system is knowledgeable and we are able to pull up the documents verifying the coding, we are pushing those through without a coder looking at them. If we do have something in question that the team is looking at, then they push those over to our coders to re-verify. But we are looking at them, because, as we've stated before, if they're asking for hundreds of notes and we send those in and they identify that they are level threes, then the pull increases.

[11:56] Scott: Quick comment or question. Obviously this takes a ton of effort from your RCM team, and a lot of the practices out there may not have that capacity, or may have to look elsewhere to get that capacity. Is this a temporary need for additional help? Do you eventually see the downcoding subside once you appeal, or show that you know what you're doing, or prove that you're minding the store? Does it ever get better, or is this just going to be an ongoing "have to hire somebody" or add more human power to the situation?

[12:37] Marianne: At this point we've done overtime projects. Depending on the amount of requests we have with a client, we've actually pulled in other resources, our coding team, to come and help get these things processed through for practices that don't have those resources. I think it does take their team having to work some overtime to get these done, because ignoring them means either you're at a loss of money, or the payer is winning when we're not appealing these. And yes, I do see that some people are reaching out for additional help, either because they don't have the knowledge for the appeals, they don't have the amount of staff to handle the amount that's coming in, or they identified it late and now they're under a time crunch to get those back in within the next two weeks, under the 45 days that some of the payers have.

This is something that I've seen increasing in the past two years, and as Mark had me on here today, venting yesterday to him, this increase is causing such a substantial amount of work. Like I said before, we're under a time crunch to get these in, and then the payer is not in any time crunch to get those back and reprocessed. So it is taking such a significant amount of time for our staff to do this that I can only imagine if you had one person on your billing team who had to start processing these through, and then also tend to the rest of your practice and try to work your AR.

[14:08] Scott: It seems like it has to happen now, and you have to identify it now, because you're on that ticking clock and you've got that 45-day window. Wow. That's a tough thing for a lot of urology practices out there.

[14:24] Marianne: Correct. And we're seeing that if you don't catch it right away, and you catch it a couple of weeks or a month later, or even after the time limit, and you're trying to backtrack through there, this is where the real help might be needed, where you have to reach out and find somebody who can help you get these things reprocessed, or ask for their expertise.

You had asked another question. The payers state that they will remove people from this automatic downcoding once they've proven themselves. I believe Humana is a 70 percent. Some of them have a metric where you're supposed to come off of that. But I don't see that automatically happening most of the time. So if you have provider reps, which some people don't because they're short-staffed in that realm, but if you have provider reps at payers, call them to ask them to remove you, saying, "We've successfully appealed and won 70, 80, 90 percent of these downcoding issues. Please remove us from this downcoding." They will. But I will tell you, I've also watched them put them right back on, sometimes 30 days, sometimes six months later. You have to watch this very closely, because the downcoding has increased significantly over the last year.

Prioritizing the team and sending the complete record

[15:31] Scott: Jeez.

[15:32] Mark: Before we move on, I think one of the important things Marianne brought up in all of this is really prioritizing everything. You can't just focus on one thing with all of this happening. We've had to stagger what everybody works on, so it's a constant management process of the AR team and the resources to make sure you're covering information as it comes in and getting it back out in a timely manner. It's easy to over-focus on these things and panic when they come in the door, and that's been something Marianne's been really strong about with the team: getting prioritized, limiting how much time you focus in each area, but still touching everything based on the time that it's due. So it's stack, pack, and rack, and redo things, and really allocate your team appropriately.

[16:31] Marianne: I cannot state that enough, because, like Mark was saying, when it's panic mode and you are only working on one thing, then the other things fall behind, and then you're always playing catch-up. You really do have to take your eight-hour day and divide it up with your team to say, "I need you to come in, work on your denials, rejections, and valids in the system. Then I need you to do your emails, and then I need you to spend two hours on this and the rest of it on this project," so that you know at least you're getting through what needs to come in and you're identifying any issues that might be coming over. If you have a very expensive drug coming in that you need to identify, have them work on that appeal first, then work over on this project. Because we're seeing this jumping over to one project, and then your eye comes off some other items, and then you just get done with this project and you have another project waiting for you.

And really and truly, I want to also say, like I've said 100 times before, make sure the team that is looking at your records and sending them in to your payer knows what records to pull, that they're pulling the complete record for what was billed on that claim, even if it's just for the E/M. Don't just send records for the E/M. If urodynamics were on the claim too, make sure you're sending the entire medical record, because if you don't have something in there that was on the claim, we are also seeing the payers come back and take back other items that were on that claim, stating the medical records did not support them. Yes, we're going to pay you for your 99214, but by the way, your records don't support your urodynamics because you didn't send in the results, and therefore they're taking those back. So this balance of everything that's happening is significant in how the payers are processing claims. In that same realm, recoups and takebacks are on the rise everywhere, and it is also inundating us, because these are things that many practices don't actually know are happening, because they're coming on the remits as an automatic recoup.

Whac-A-Mole: reading EOBs and auditing remits monthly

[18:32] Scott: Ray, how about you? Any comments, questions?

[18:34] Dr. Ray Painter: Marianne, when you were in Vegas at Circus Circus, were you good at playing Whac-A-Mole?

[18:40] Marianne: That's really funny, because another doctor said that. They said this is a game of Whac-A-Mole. It really is. It was one of my favorite games at Chuck E. Cheese when my kids were little.

[18:49] Ray: It sounds like you're making the case that people ought to look at their EOBs timely, because if you see something like this happening, you want to nip it in the bud early, or we know those payers are just going to keep on doing it, so you've got more and more piling up.

[19:12] Marianne: Correct. If practices can implement, just like you do in coding, a monthly monitoring and auditing of your practice, and let's say your top payers are Blue Cross, UnitedHealthcare, Medicare, have the person who's leading your RCM team go and look at three remits per payer each month to be certain that your system posted things correctly and that your team posted things correctly. That is what we're doing on our end, pulling up those remits, because that's how you're going to identify it, because there are different remittance codes that they use each time. I was explaining this to my husband at one point, and he was like, "Okay, how do you work this out?" It's like the spam calls. You get a spam call, and it says, "Press nine if you want to be removed from our list." Then the next day, the same company calls you, it's just a different number that's one digit off. This is exactly what's happening, I believe, with remits. They're coming through, and they're changing the remittance code. You get one process in, and you get the people looking for that remittance code, and the next remit comes in, and there's a different remittance advice code coming in for the denial. So really paying attention and pulling those EOBs will also help you audit your systems.

Sponsor and final thoughts: billing is a team sport

[20:32] Scott: Great advice. All right, I think we need to wrap this episode up here, and we'll get some final thoughts. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prsnetwork for specials for our listening audience. I know there was a lot said here. What we want to do is go around and get some final thoughts, maybe some summary actions. There's so much going on and so many things to look at, and so little time and resources from a urology practice's point of view. It's hard to know what to prioritize. Let's go around the horn. Let's get some final thoughts from Mark first.

[21:12] Mark: I have to say, first off, this is just wrong, the way everything is happening at this point in time. The payers are running roughshod, burying people in administrivia and not allowing them to care for their patients. But that's the game we're stuck in, and it really goes back to a couple of different things. When I consider talking to physicians around the country in different groups, especially in the C-suite, they're essentially focused on the fact that clean claims solve all problems. And I don't want to discount clean claims. Clean claims going out the door, making sure that you know what you've coded and how you've documented everything, that you're scrubbing and adding the appropriate modifiers and checking against the LCDs, and the diagnosis codes are in the right spot, all of that is absolutely key.

It is something that makes everybody's lives easier, but it doesn't solve everything. I think a lot of physicians I speak with think that billing is easy, just a pushing-buttons type of activity, and the reality is it's much more than that. It's not only pushing those buttons and making sure that the double checks are in place, but it's also the follow-up. If you don't have faith in the original documentation and coding to turn those things around, to respond to medical record requests, or to go through a RAC review or a denial for any reason whatsoever, then you've got to add extra resources to review the records before they go back out the door and make sure that all your I's are dotted and your T's are crossed. Because if you're putting information out there that results in a second denial, it's not just that claim. What we're seeing is it expands to more claims, because their assumption is, if you got this wrong, you're getting everything else wrong, and we're going to keep digging. So you need that front end, and again, I'm not dismissing it, but you also need a very strong back end.

As Marianne mentioned, you're going to leverage your AI tools where you can, and you want to make sure that your AI is being double-checked and monitored, because we've seen some of that be incorrect from the AI standpoint, or you've got physicians who are maybe using the AI in part but not in full, and the integration with your electronic medical record isn't there to collect everything. So there are lots of double checks that need to go into this system at present, and it is causing a lot of work and a lot of stress. I've taken a number of calls recently on PCR denials. I've taken calls on RAC audits in various things we're doing with PAE and some of the other things we've talked about. Then we've got this basic downcoding, and then these stealth denials, which are glitches that the payers are not responding to in a positive manner, and that administratively makes it more difficult. It's death by a thousand cuts, or death by big ones. It is top to bottom.

The last thing I'll add is my standard push on clinical pathways. The more you can get consistency in the documentation and treatment protocols on the clinical side, the easier it is to defend those going through the back end when we get these ridiculous denials or the look-backs from Medicare through RACs or even through the UPICs. All of this needs to be really analyzed and carefully monitored up front. You need protocols for these high-target areas. PCR shouldn't be run on every single patient. Quant UA shouldn't be run on every single patient. There should be specific criteria, and those protocols need to be stated by the practice and followed by the practitioners, and the documentation needs to be there for everything that needs to be supported in this overall process.

It's not going to get any easier as we look forward. Certainly, there's got to be something we can do with some of this ridiculous downcoding and these fake denials, these glitch denials. Those types of things should be looked at as areas where maybe we need some lawsuits, we need some activity from the state legislature, because the other part of this, as Marianne mentioned, is the delay in payment. This is just money in the wrong spot at the wrong time, in a timeframe where we can't afford all this. So it's unfortunately not good news, but overall you can increase your efficiency top to bottom, and it takes everyone. As we've always said, billing is a team sport, and there is no island out there that goes untouched by all of this.

[26:54] Scott: It's so true. All right, Marianne, final thoughts?

[26:57] Marianne: My final thought is the same as what Mark was saying. I just want to keep reiterating this is a team sport. This is focusing on your front end, making sure your insurance information is accurate and correct in your system, to allow those denials to decrease so that your AR team can focus on these more high-level items and these medical records pulls they're doing, to make sure they can identify RAC audits. As we've talked about before, and Mark was saying, education, not just for your clinical team regarding procedures. If your AR team understands the procedures and the items being billed in your practice, and understands how you deliver that to the patients, they will be better able to appeal and understand what they're doing on the back end when they're appealing and sending these medical records.

And really make sure you are identifying key people who can focus on the review part. You can have medical records sent, but make sure there are processes in place so they understand which medical records to send, and that somebody's auditing that. As we were just talking about with AI, if the payers are using AI and they're able to push these things through quicker, and that's why we might be seeing the increase on our end, we have to be able to tackle that on our end and do it accurately, because this will get quicker as things turn around faster. I'm seeing them come back a lot quicker in their denials and the frequency of them. So really just make sure everybody in your practice understands your practice as a whole, what you're doing, and that you have all the processes in place to audit everything that's going on in your practice.

I'm going to reiterate as well on the clinical pathways: those also help with the appeals, because then you have a pathway that you know is being followed in your practice, and you have the confidence that when those items are requested and pulled, those medical records are meeting those pathways. So those are helping with the denials, and that's helping with the appeals on the other end. And something I've learned here at PRS: not appealing these things, not paying attention to these things and not fighting the payers is not the answer, because if you just ignore them and you don't have a way to appeal the downcoding or the medical records pulls, you will end up just allowing the payer to win on that end.

[29:25] Scott: Great points. Thank you, Marianne. All right, final word to Ray.

[29:31] Ray: I think we're being punished for the sins of the past, by the docs that did not pay attention to documentation guidelines and charged levels they shouldn't have charged, and also by practices that didn't follow up on denials. We've allowed the new AI systems to be programmed with erroneous data for those of us who are trying to do it right. So we have to pay for those sins by being ever diligent and being sure we're doing it right today, all the way from documentation to coding to billing to follow-up.

[30:16] Scott: Well said. All right. That's all we have for today. Thank you, Marianne, for joining us, and thank you everybody for listening. Take us out, Ray.

[30:27] Ray: Happy coding and billing and follow-up.

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