Illinois SB3114 aims to enhance transparency and fairness in health insurance downcoding practices.
The Transparency in Downcoding Act seeks to regulate how health insurance issuers handle downcoding, which is the practice of reducing the level of a medical service code on a claim, resulting in lower payment. The Act prohibits downcoding based solely on diagnosis codes, mandates that downcoding decisions be made by a physician with relevant expertise, and requires issuers to use a documented review of clinical information. It also bans the use of automated systems for downcoding and prohibits targeting or discrimination against physicians treating complex or chronic conditions.
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- Legal Framework
- Critical Issues
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