Overbilling vs. Downcoding — The Battle between Physicians and Insurers

Abstract

In September 2004, a federal appeals court upheld a class-action lawsuit on behalf of physicians who charged that their patients' insurance companies had conspired to curb reimbursement for the physicians' services. The judge described the case as “almost all doctors versus almost all major health maintenance organizations”1 (see table). The case has revealed issues that have long lurked beneath the surface of the managed-care revolution. Physicians are accused of driving up costs and exploiting the third-party–payer system by overcharging for their work. Managed-care organizations are accused of systematically obstructing and delaying payment for legitimate services in order to improve their . . .