1. United States
2. Texas
3. Letter

I am a licensed professional counselor and co-founder of a group counseling practice in Austin with roughly 50 clinicians. I am writing about an insurance practice that is quietly reducing access to mental health care in the state. A health plan we contract with has begun changing our psychotherapy claims after already paying them, reclassifying 60-minute sessions as 45-minute sessions and demanding refunds. Under our contract the longer session pays double, so a downcoded claim is cut in half. The company never requested a single clinical note, treatment plan, or intake before making these determinations. It has never seen our documentation. When we file an appeal, the AI determination comes back in seconds. We are working through several hundred of these claims, and we are not the only practice affected. Things like this are causing clinicians to leave the field. We are seeing something similar in medicine with automatic downcoding of e/m codes. Senate Bill 815 was the right instinct. It bars an automated decision system from making an adverse determination and gives the Texas Department of Insurance authority to audit how these systems are used. But the law was written around prior authorization. Downcoding is a decision made after care has already been delivered, so it may fall outside the statute entirely. A company that cannot use software to deny a session in advance can still use software to reprice it afterward and take the difference out of the next payment. Three things would help: 1. Extend the human review requirement in SB 815 to cover post-payment coding changes and claim repricing. 2. Ask TDI to use its existing audit authority now, and to confirm that prompt pay protections are being enforced, specifically the 180-day limit on recoupment and the bar on offsetting while an appeal is open. 3. Request an interim charge on automated claim adjudication before the 90th Legislature convenes. I would also encourage your office to work with NASW-Texas. Their members are seeing this statewide, and they can bring you documented cases. I am glad to provide our records and to testify if that would be useful.