Practice viability is a central concern for Colorado physicians, as it underpins their ability to care for patients and maintain their practices. The Colorado Medical Society (CMS) has highlighted several challenges facing medical professionals in the state, including downcoding by health plans, prior authorization barriers, insurer consolidation, and regulatory issues.
One major issue is the use of automatic downcoding programs by some health plans. These programs reduce physician reimbursement without reviewing medical records or providing adequate notice. According to CMS, this practice violates Colorado Division of Insurance Regulation 4-2-17. The regulation requires that any reduction in reimbursement be treated as an adverse determination, which means timely notice, clear explanations, and an opportunity to appeal must be provided.
Nicole Allison, practice manager for Dynamic Athlete in Boulder, described the impact: “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 notified the Division of Insurance about these concerns and sent letters to Aetna, Anthem, Cigna, and UnitedHealthcare. The organization is also offering resources such as tools to identify downcoding and guidance on regulatory violations through its members-only resource page at cms.org/info.
Significant reforms to Colorado’s prior authorization laws took effect on January 1, 2026 under HB24-1149. These changes aim to reduce administrative burdens on physicians and improve transparency in the process. For example, approvals for medical services now last one year or the full length of treatment. Insurers must also identify covered alternatives when denying requests and review prior authorization requirements annually. For prescription drugs considered chronic medications (unless high-cost), approvals last three years.
Surgical practices benefit from new safeguards preventing insurers from denying coverage for related procedures during approved surgeries if delays would risk patient safety. Carriers can no longer retroactively deny payment for approved surgeries based on intraoperative services.
Insurers are now required to offer provider exemption programs that reduce or eliminate prior authorization requirements for qualifying physicians. CMS encourages practices to update their workflows accordingly and provides detailed guidance on its resource page.
Another ongoing concern involves a federal antitrust lawsuit against MultiPlan (now Claritev) and several large insurers including UnitedHealth, Elevance (Anthem), Humana, Aetna, Cigna, and Blue Cross Blue Shield entities. The lawsuit alleges that MultiPlan’s pricing tools were used by insurers to coordinate suppression of out-of-network payments below market rates.
The case is proceeding in federal court in Illinois after key legal hurdles were cleared—most notably when the U.S. Department of Justice filed a statement of interest in March 2025 supporting the seriousness of the allegations; then in June 2025 when defendants’ motion to dismiss was denied.
Physicians who have been paid out-of-network rates may be entitled to financial damages going back ten years if they can show their claims were repriced using MultiPlan’s systems. Those interested can contact court-appointed lawyers or access resources at napolilaw.com/en/%20multiplan.
A proposed class action related to these issues is also being litigated but a decision on class certification is not expected until 2027; providers may still join individually before then.
