Protecting Colorado physicians’ ability to practice

Cecilia Comerford-Ames

CMS Communications and Marketing Manager

Practice viability is not an abstract policy concept – it is the foundation that allows physicians to care for patients, sustain their practices, and have successful and satisfying careers. From downcoding and prior authorization barriers to insurer consolidation and regulatory overreach, the pressures on physician practices continue to intensify. Ensuring that Colorado physicians can practice medicine without unnecessary interference is one of our highest priorities. We have information and tools for you.

Right code, right care: Stopping health plan downcoding

Several health plans have implemented automatic downcoding programs that reduce physician reimbursement without reviewing medical records or providing meaningful notice. These practices directly violate Colorado Division of Insurance Regulation 4-2-17 and represent a fundamental breach of the physician-payer relationship. Any reduction in reimbursement – whether made before or after care is delivered – meets the regulation’s definition of an adverse determination and requires timely notice, a clear medical and contractual explanation, and a meaningful opportunity to appeal. Automatic downcoding fails on all counts, creating a “guilty until proven innocent” approach that undermines due process, threatens practice viability, and ultimately limits patient access to complex care.

Rebranding these reductions as “payment adjustments” or relying on algorithms does not change the legal standard. Under Colorado law, reduced payment is a reduced benefit, and health plans must follow established protections. 

“As a small business, automatic downcoding creates a significant issue for us,” said Nicole Allison, practice manager for Dynamic Athlete in Boulder. “We have to divert resources to spend time appealing the unsubstantiated downcoded claims. If the claims are ultimately not reversed, it creates a loss of revenue, which will become problematic quickly and ultimately affects patient care and access.”

The Colorado Medical Society (CMS) has formally notified the Division of Insurance and sent letters to Aetna, Anthem, Cigna, and UnitedHealthcare. CMS has provided and will continue to develop tools to identify downcoding, template letters, guidance on regulatory violations, and instructions for submitting complaints – because fair reimbursement is essential to sustaining physician-led care. Resources are available on the new CMS members-only practice resource page, cms.org/info, linked from the QR code on this page.

Prior authorization reform: New protections now in effect

As of Jan. 1, 2026, major reforms to Colorado’s prior authorization laws are now in effect under HB24-1149, bringing meaningful improvements for physicians, care teams, and practice operations. These changes reduce administrative burden, improve transparency, and help protect timely access to medically necessary care – critical components of practice viability.

For medical services, prior authorization approvals now last for one year or the full length of treatment. When a request is denied, insurers are required to identify covered alternatives, and carriers must conduct annual reviews to eliminate prior authorization requirements that are no longer clinically necessary. For prescription drugs, chronic medications now receive three-year approvals unless classified as high-cost, and insurers must publicly post searchable formularies and clinical criteria.

Surgical practices benefit from important new safeguards. When an approved surgery requires an additional or related covered procedure during the operation, insurers may not deny coverage if delaying care would place the patient at risk. Carriers are also prohibited from retroactively denying payment for approved surgeries based on related intraoperative services.

The law also requires insurers to implement provider exemption programs that reduce or eliminate prior authorization requirements for qualifying physicians. CMS encourages practices to review workflows now and take full advantage of these new protections. Detailed guidance and tools are also available on the new members-only CMS practice resource page.

Ensuring accountability: What the MultiPlan case could mean for Colorado physicians

CMS is closely tracking a federal antitrust lawsuit that could have significant financial implications for Colorado physicians who have been paid out-of-network rates by large commercial insurers.

The lawsuit is against MultiPlan (recently rebranded as Claritev) and several major insurers including UnitedHealth, Elevance (Anthem), Humana, Aetna, Cigna, and various Blue Cross Blue Shield entities. MultiPlan’s pricing tools – operating under names such as Data iSight, Viant, NCN, ProPricer, and MARS – are alleged to have played a central role in a coordinated effort to suppress out-of-network payments.

According to the allegations, insurers relied on MultiPlan’s data to align out-of-network reimbursement at artificially low levels, rather than allowing prices to reflect independent market negotiations. If proven, this conduct may have systematically underpaid physicians and health care facilities for years – without their knowledge or ability to negotiate fairly.

Many Colorado physicians may not realize their claims were repriced using MultiPlan’s systems. Clues can often be found in Explanations of Benefits or remittance advice, though the involvement of MultiPlan is not always transparent.

The case, consolidated in federal court in Illinois, has passed key legal hurdles. In March 2025, the U.S. Department of Justice filed a statement of interest underscoring the seriousness of the allegations. In June 2025, the court denied the defendants’ motion to dismiss, allowing the litigation to proceed into discovery.

For physicians, this progress signals a meaningful opportunity for scrutiny of insurer practices that have long raised concerns about fairness and transparency in payment.

Physicians and health care providers who have been out-of-network with major insurers may be entitled to financial damages for claims dating back to 10 years. Those interested in learning more can contact one of the lawyers appointed by the court to lead non-class claims or access resources, including a free case evaluation, at napolilaw.com/en/%20multiplan.

The court also has appointed attorneys to litigate a proposed antitrust class action on the same issues, but a ruling on any proposed class certification is not expected until 2027. Providers who believe they have been impacted by MultiPlan’s conduct can join the litigation individually on a non-class basis and do not need to wait for any ruling on a proposed class. Stay tuned.

The legislative and regulatory arena

The legislative and regulatory arena has a direct and lasting impact on practice viability. Many of the pressures physicians face – administrative burden, payment delays, and coverage restrictions – are shaped by laws and regulations far beyond the exam room. CMS works tirelessly in this space to protect physicians’ ability to care for patients and sustain their practices. As you’ll see in this issue of Colorado Medicine, advancing practice viability remains a central focus of our efforts.

Practice viability advocacy works best when it is informed by real-world experience. The tools, template letters, legal actions, and legislative strategies outlined here exist because physicians told us where the system is breaking down. When you encounter inappropriate downcoding, unreasonable prior authorization demands, or insurer practices that interfere with patient care, we need to know. Use our template letters when insurers are out of line, and tell us when you engage so we can track patterns, escalate issues, and push for systemic fixes. Your feedback drives our work – and your engagement strengthens it. Please stay connected, reach out early, and interact with your Colorado Medical Society so we can continue to protect your ability to practice medicine in Colorado.