Practice viability is an essential element for Colorado physicians to continue providing care and maintaining their practices, according to the Colorado Medical Society (CMS). The organization has raised concerns about several challenges that threaten this viability, including automatic downcoding by health plans, prior authorization requirements, and payment practices by large insurers.
Automatic downcoding programs have been introduced by some health plans, reducing physician reimbursement without a review of medical records or proper notification. CMS states that these actions violate Colorado Division of Insurance Regulation 4-2-17, which requires timely notice, a clear explanation, and an opportunity to appeal any reduction in reimbursement. “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.”
CMS has informed the Division of Insurance about these practices and contacted major insurers such as Aetna, Anthem, Cigna, and UnitedHealthcare. The society is also offering resources for physicians on identifying downcoding issues and submitting complaints through its members-only resource page at cms.org/info.
Changes in prior authorization laws took effect on January 1, 2026 under HB24-1149. These reforms aim to reduce administrative burdens for physicians by extending approval periods for medical services and chronic medications. For example, prior authorization approvals now last up to one year for medical services or three years for chronic medications unless they are classified as high-cost. Insurers must also provide alternative options when denying requests and conduct annual reviews to remove unnecessary requirements.
Surgical practices benefit from new protections that prevent insurers from denying coverage if additional procedures are needed during surgery and delaying care would risk patient safety. Carriers can no longer retroactively deny payment for approved surgeries based on related intraoperative services. Insurers must also implement provider exemption programs that lessen prior authorization requirements for qualifying physicians.
CMS is monitoring a federal antitrust lawsuit against MultiPlan (now Claritev) and several major insurers—including UnitedHealth, Elevance (Anthem), Humana, Aetna, Cigna, and various Blue Cross Blue Shield entities—over alleged efforts to suppress out-of-network payments using MultiPlan’s pricing tools such as Data iSight and Viant. The case alleges that these systems were used to keep reimbursements artificially low rather than allowing market negotiations.
The lawsuit is proceeding in federal court in Illinois after surviving motions to dismiss in June 2025; the U.S. Department of Justice filed a statement supporting the seriousness of the allegations earlier that year. Physicians who have been paid out-of-network rates may be eligible for financial damages going back ten years. Information about non-class claims can be found at napolilaw.com/en/%20multiplan.
Class action litigation is also underway but may not see certification until 2027; providers can pursue individual claims before any class action ruling.
