IFM | Downcoding: How Payers Are Cutting Payments and What Family Physicians Can Do

Guest host Karen Johnson, PhD, VP of Practice Advancement for the AAFP, talks with Dr. Tina Philip, DO, a solo family physician in Round Rock, Texas, and AAFP CEO, Shawn Martin, about payer downcoding, where insurers reduce billed evaluation and management levels (e.g., 99214 to 99213), lowering payment and adding administrative burden. Dr. Philip describes how downcoding most often affects moderate-to-high complexity office visits and stresses physicians must monitor claims beyond denials by working with billing/coding staff to confirm expected reimbursement. Martin explains downcoding as an evolution of coding integrity programs amplified by AI-enabled scale and as a less visible cost-control approach than prior authorization, often with limited transparency and historically few appeals. Topics By Timestamp 01:01 Why Family Medicine 02:32 What Downcoding Means 04:02 Why Payers Downcode 08:40 Spotting It in Practice 10:51 Who Should Investigate 12:07 AAFP Advocacy Efforts 15:17 Undercoding and Appeals 18:04 Tools and Next Steps 20:29 Final Thoughts Additional Resources Coding for Evaluation and Management Services: FAQs Letter template for writing to payers about ending downcoding policies The AAFP Advocates Against Payer Downcoding Policies and For Improved Primary Care Payment AAFP urges feds to investigate downcoding as threat to primary care | Advocacy and Government Cigna's downcoding policy gets pushback from physician groups | AAFP Disclaimer: Copyright 2026. AAFP. The views presented in this broadcast are the speaker's own and do not represent those of AAFP.  The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.  AAFP makes no representation as to the accuracy or completeness of the information and is not responsible for results that may arise from its use.  Consult an appropriate professional concerning your specific situation and respective governing bodies for applicable laws. Reference to any specific product or entity does not constitute an endorsement or recommendation by AAFP unless specifically stated otherwise.  AAFP and the AAFP logo are registered trademarks of American Academy of Family Physicians.