In this episode of the Ask MGMA Podcast, hosts Daniel Williams and Christy Good dig into one of the most urgent issues medical practices are facing: payer downcoding and the increasing influence of artificial intelligence in reimbursement decisions. Discover why evaluation and management (E/M) claims are being reduced without medical record review, how automated systems are affecting your revenue, and what actions you can take to identify, track, and appeal unjustified downcodes. Whether you're feeling the impact already or want to stay ahead of the curve, this conversation offers practical tips and valuable resources to support your team.

Key Highlights

• 0:53 – Welcome & Topic Overview
  Daniel and Christy introduce the episode and the rising issue of AI-driven downcoding.
  1:53 – What is Payer Downcoding?
  Christy explains how downcoding works, what’s changed with AI, and why it goes against CMS guidelines.
  3:19 – How AI Flags Claims
  An inside look at how AI uses historical data to decide what gets downcoded — and why that’s problematic.
  4:05 – The Impact on Providers
  More than lost revenue — learn how this practice increases administrative burden, delays payments, and affects provider profiles.
  6:04 – Spotting the Red Flags
  Key signs your practice may be getting downcoded and what to look for on remittance advice.
  6:39 – What to Do If You’re Affected
  Steps to track, appeal, and escalate — and why reporting to MGMA and AMA matters.
  8:15 – Strengthening Your Documentation
  Avoid copy-paste notes and use specific language to reflect true complexity of care.
  11:23 – Using AI to Your Advantage
  How practices can deploy AI tools to clean up claims and reduce rejections — plus why human oversight is still key.
  12:53 – Advocacy and Policy Action
  How to get involved with MGMA’s Government Affairs team, the AMA, and your state’s insurance department.
  14:51 – Top Three Takeaways
  Christy recaps what every practice should remember: be vigilant, be proactive, be connected.

Direct Links and Resources

• 📧 Contact Ask MGMA: [email protected]
• 🧠 MGMA Consulting Services: [email protected]
• 💬 Join the MGMA Community Discussion
• 📢 Report Issues to MGMA Government Affairs: [email protected]

Additional Resources:

• MGMA Events
• MGMA Consulting
• MGMA DataDive
• MGMA Stat
• MGMA Podcasts

Sponsor:
Capella University helps healthcare professionals earn their MHA on their terms. Their FlexPath MHA program is designed for busy MGMA members who want to advance their leadership skills with a flexible, self‑paced format — often faster and more affordably — without putting their careers on hold. Questions? Visit capella.edu/MHA to learn more.