The Colorado Medical Society (CMS) is emphasizing the importance of practice viability as a core element in ensuring patient care across the state. The organization highlights ongoing challenges faced by physicians, including reimbursement issues, administrative burdens, and regulatory hurdles.
Automatic downcoding by health plans has emerged as a key concern for many medical practices. Some insurers have implemented programs that reduce physician payments without reviewing medical records or providing proper notice. CMS states that these actions violate Colorado Division of Insurance Regulation 4-2-17, which requires timely notification and an opportunity to appeal any adverse determination related to payment reductions.
Nicole Allison, practice manager for Dynamic Athlete in Boulder, described the impact on smaller practices: “As a small business, automatic downcoding creates a significant issue for us. 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.”
CMS has formally notified both regulators and major insurers about these concerns. The society is offering tools and guidance to help members identify downcoding practices and file complaints when necessary. More information is available through their members-only resource page at cms.org/info.
Recent changes in Colorado law have also addressed prior authorization requirements for medical services and prescription drugs. Under HB24-1149, which took effect January 1, 2026, approvals for most medical services now last up to one year or the duration of treatment. Insurers must also provide alternatives when denying requests and review prior authorization requirements annually to ensure they remain clinically necessary.
For chronic medications not classified as high-cost drugs, approvals can now last three years. Insurers are required to publish searchable formularies with clinical criteria online so providers can more easily determine coverage details.
Surgical practices receive new protections under this law as well. If an approved surgery leads to additional covered procedures during an operation that cannot be delayed without risk to the patient’s health, insurers may not deny payment retroactively based on those related services.
Insurers must implement exemption programs that lessen or remove prior authorization requirements for certain qualifying physicians. CMS encourages its members to review internal workflows so they can benefit from these changes.
In addition to legislative reforms, CMS is monitoring a federal antitrust lawsuit against MultiPlan (now Claritev) and several large insurance companies—including UnitedHealth, Elevance (Anthem), Humana, Aetna, Cigna, and Blue Cross Blue Shield entities—over alleged suppression of out-of-network payments using pricing tools such as Data iSight and Viant.
The lawsuit alleges that MultiPlan’s systems enabled coordinated efforts among insurers to keep out-of-network reimbursements artificially low rather than allowing market-driven negotiations. This case has advanced past several legal challenges; in March 2025 the U.S. Department of Justice filed a statement highlighting its seriousness https://www.justice.gov/opa/pr/justice-department-files-statement-interest-antitrust-class-action-against-multiplan-and-major-insurance-companies , and in June 2025 the court denied defendants’ motion to dismiss https://napolilaw.com/en/%20multiplan , moving it into discovery phase.
Colorado physicians who were paid out-of-network rates may be eligible for damages going back ten years if their claims were repriced using MultiPlan’s systems—a process sometimes visible on Explanations of Benefits or remittance advice forms but not always transparent.
Providers interested in learning more about their options can contact court-appointed lawyers leading non-class claims or access resources—including free case evaluations—at napolilaw.com/en/%20multiplan https://napolilaw.com/en/%20multiplan . While class action certification remains pending until at least 2027, individual providers do not need to wait for that decision before pursuing separate claims if they believe they have been affected by MultiPlan’s conduct.
