Ask Blue Cross and Blue Shield of Montana What It Means by “Accurate Billing.”

Behavioral Health Business reported that 17% of Big Sky Psychiatry’s adult claims and 39% of its pediatric claims were downcoded in July; Blue Cross and Blue Shield of Montana had said its July 1 edit would “help ensure accurate billing and proper reimbursement.” As of Sept. 30, 2026, the Blue Cross notices and Illinois coding policy this edition examined do not say what the review weighed on any one claim.

Here, “downcoded” means paid for a lower level than billed. In a letter Behavioral Health Business obtained, Dr. Leonard Lantz, whom the outlet identifies as a psychiatrist at Helena, Montana-based Big Sky Psychiatry, wrote: “Please look at BCBSMT’s pattern of downcoding all the selected claims to 99213.” The number is his, and it stays his here. Across the practice’s claims, the outlet reports, 17% of adult patients’ claims and 39% of claims for pediatric patients were downcoded in July.

Lantz told the outlet he and a colleague at the practice logged nearly 23 hours in July outside of clinical care, fighting between 40 and 50 downcoded claims. The letter, as the outlet quotes it, goes on: the method of assigning all downcoded claims to 99213 “definitely does not ‘ensure billing accuracy.’ Instead, it appears to be an arbitrary, flawed payment practice.” The insurer’s notice for the July 1, 2026 change, dated March 16, 2026, states the purpose in its own words: the edit will “help ensure accurate billing”.

The notices, and what a level is

The Blue Cross and Blue Shield of Montana notice dated March 16, 2026 states: “Effective July 1, 2026, we’ll enhance our claims editing and review process for office, inpatient and outpatient evaluation and management services for our members with commercial plans.” Its purpose: the editing enhancements “will help ensure accurate billing and proper reimbursement.” Under “What’s changing,” the notice sets the test: if services billed do not support the level of E&M services billed, “your reimbursement will be for a lower level of service validated.”

The Illinois plan’s notice of the same date carries the same purpose; it and the Texas, Oklahoma and New Mexico plans’ March 16 notices carry the same “lower level of service validated” sentence. On Sept. 10, the Illinois plan wrote: “Effective July 1, 2026, we refined our claims editing and review process”. Montana Public Radio, which identifies Julian Thorne as a Helena-based psychiatrist on the Montana Psychiatric Association’s board, reports his explanation: providers code up to a level five, and the higher the number, the more complex the visit. Thorne says it is “based on number of diagnoses addressed as well as, like, tests ordered, if there were tests, medications managed, that kind of thing.” Illinois’s coding policy, CPCP024, effective Feb. 23, 2026, bases the level on medical decision making or total time, and defines medical decision making as “the documentation of the complexity by establishing a diagnosis, assessing the status of a condition, and/or selecting a management option”.

Two descriptions of one edit

A BCBSMT spokesperson told Behavioral Health Business the process is “well designed and intended to appropriately support accurate payments of correctly coded claims for the level of service reflected in the claim,” and “does not ‘automatically downcode’ claims or use artificial intelligence to make decisions regarding E/M levels in claims.” In Illinois, the Chicago Sun-Times reports the insurer’s description, accurate payments “for the level of service that was provided,” and reports that BCBS did not comment on whether it was using an AI tool. In the Blue Cross notices and policy documents this edition read, through Sept. 30, 2026, the words “artificial intelligence,” “AI,” “algorithm” and “automatic” do not appear about the July edit; the word “software” appears only in the phrase “coding software logic,” in Illinois’s policy preamble.

Montana Public Radio reports that Blue Cross said it changed how it evaluates what providers bill for, to “ensure claims are submitted with accurate and complete information.” The station reports that the Montana Psychiatric Association and the Montana Association of Pediatric Psychiatrists filed complaints. Montana Public Radio quotes Julian Thorne, a Montana psychiatrist: “If you’re doing extra work because a patient needs it, and the insurance is not reimbursing for it, then it disincentivizes you from doing that.”

We read this as two descriptions of one edit, placed side by side here, not by either party. In the notice’s account, the purpose is “accurate billing” as well as “proper reimbursement.” In Thorne’s, unreimbursed extra work a patient needs discourages doing it; in Lantz’s, as the outlet quotes his letter, the method of assigning all downcoded claims to 99213 appears to be an arbitrary, flawed payment practice. Neither description is a finding about any one claim.

What the documents examined here leave open

The Montana and Illinois notices state a route under “What happens next,” for a provider who disagrees. Illinois’s policy adds three possibilities: records and itemized bills “may be requested from the provider for review to validate the site of service, level of care rendered, and services billed were accurately reported”; medical records “may be reviewed to determine the extent of history, extent of examination performed, complexity of medical decision making (MDM), and services rendered”; codes and modifiers it mentions “may be subject for review before payment can be made.” None says whether, or when, that happens for a given claim. As of Sept. 30, 2026, none of the notices, policy or provider pages examined here states what the July review drew on for any one claim. Which description fits a given claim?

The Montana and Illinois plans’ March 16 notices say that a provider who does not agree with the level of service reimbursed “may submit medical records to support your claim.” Dr. Erin Amato of Montana Psychiatry and Brain Health Center in Billings told Behavioral Health Business: “In theory, the downcoded claims can be appealed, but in practice, each appeal takes staff a significant amount of time, documentation, and then follow-up.” In some cases, the outlet reports, providers lost $60 to $110 per claim against what the plan previously paid.

The regulator and the Act, by date

A spokesperson for Montana’s Commissioner of Securities and Insurance told Behavioral Health Business that “CSI is aware of the complaints and is engaging with Blue Cross on the matter” but provided no other comment. On Aug. 31, 2026, separately, a release from the same office, the Office of the Montana State Auditor, stated that State Auditor James Brown initiated the first market conduct review of BCBSMT in more than a decade. The release says opening a review “does not mean that the Auditor’s Office has determined any violation of law or regulation by BCBSMT,” and, as fetched Sept. 30, does not mention the complaints.

Illinois’s Public Act 104-0568, the Transparency in Downcoding Act, approved July 10, 2026, takes effect January 1, 2028. Section 2 finds: “Improper downcoding may result in harm to patients by disincentivizing care for individuals with complex medical conditions.” This edition does not apply the Act to Blue Cross.

The Agentics read

Agentics reads this record through Digital Derangement Syndrome™ (DDS™): systems failing to recognize legitimate authority. The closest fit, and only a fit, is Authority Misclassification: a professional’s coded judgment of the work’s complexity is re-leveled by a review whose per-claim basis is not on the open record.

Where the argument stops

Two outlets, one excerpting a letter, carry the providers’ accounts here; the letter and complaints were not obtained. The sources this edition read, as fetched Sept. 30, 2026, contain no remittance advice, explanation of payment, claim adjustment reason code or edit code for any Montana or Illinois E/M claim reduced under the July 1, 2026 change.

Through Sept. 30, 2026, no source this edition read reports a determination by Montana’s commissioner on the complaints, and the commissioner’s news list, as loaded that day back to Oct. 7, 2025, shows no item by title about E/M payment levels or the complaints. The Montana E/M policy, behind a provider login, was not opened; the coding policy quoted here is Illinois’s. This edition will return when any of these becomes public. The mapping to Digital Derangement Syndrome™ is our editorial reading, not a finding by any party.