D.C. insurers would face limits on lowering medical claim payments

Health insurers could not use automated tools or diagnosis codes alone to downcode claims. The rules would cover insurers, third-party administrators, and other payers that decide claims for health insurers. A D.C.-licensed clinician in the treating provider's specialty would have to review the medical information and document the review. Insurers could not target doctors who routinely treat patients with complex or chronic conditions. These rules would take effect after mayoral approval or a Council veto override and a 30-day congressional review period.

Health insurers would have to explain downcoding decisions and provide an appeal process. These protections would apply whenever a health insurer lowers the service code and payment on a provider's claim. The notice would have to give the reason, the clinical criteria, the original and revised codes and payments, the reviewing doctor's qualifications, and appeal instructions. Providers would have at least 180 days to appeal and could appeal groups of similar claims without restriction. These notice and appeal rules would take effect after mayoral approval or a Council veto override and a 30-day congressional review period.

D.C. regulators could penalize violations and require corrected claim processing. Enforcement would cover violations of the proposed downcoding rules by health insurers and payers acting for them. Regulators could impose penalties of up to $50,000 per violation and order insurers to reprocess improperly downcoded claims with interest. A pattern of discriminatory downcoding could also lead to fines, restitution, or suspension of the insurer's D.C. license. These enforcement powers would take effect after mayoral approval or a Council veto override and a 30-day congressional review period.