Background
- Aetna and Cigna have announced automatic downcoding policies for complex Evaluation & Management (E/M) services — specifically, level 4 and level 5 office visits.
- Aetna and Cigna are using algorithms or claims data alone to automatically downgrade the codes physicians assign to cases — without reviewing individual patients’ medical records.
- The result is that claims for complex visits will be paid at a lower level. Physicians who disagree with this automatic downcoding will have to appeal.
- That process will require submitting a significant amount of paperwork and patient case documentation — something many practices will not have the capacity or wherewithal to do.
- This “deny first, pay later” system presumes physicians are guilty of “upcoding” until proven innocent.
Issues we are facing:
- These new policies from Aetna and Cigna do not put patients first. They’re not about catching bad actors. They’re about boosting insurer profits at the expense of patient access and timely care.
- These policies threaten the viability of independent physician practice. Automatic downcoding will accelerate the collapse of independent practices that communities rely on for accessible, affordable care.
- Insurers are acting in bad faith. Aetna and Cigna are rewriting the rules of medical coding unilaterally, disregarding physician expertise and nationally recognized standards.
Potential Scope of the Policy
- Aetna and Cigna’s policies will have the potential to impact some of the most commonly billed codes
- According to CMS data of Medicare Part B E/M codes by specialty in CY 2022, E/M CPT code 99214 was the most frequently billed E/M code (of 114 codes tracked), representing 25% of allowed E/M claims. E/M CPT code 99215 was the sixth most frequently billed E/M code in the same data set, representing 3% of all codes billed.
- Overcoding of CPT codes 99214 and 99215 is de minimis
- According to a 2024 audit of Medicare FFS claims, CPT codes 99214 and 99215 overcoding represented 0.13% of paid Medicare FFS claims in 2024.
- Cigna anticipates that this new policy will affect less than 3% of eligible claims.
* This is a significantly greater percentage of claims than CMS data would suggest are actually overcoded
- When you consider the high volume of claims this would affect, and the low likelihood that they are incorrectly coded, it is difficult to justify this policy as anything more than a way for insurers to erect even more barriers to paying physicians for the services they have already provided
Effect on Patients
- These policies will force physicians to spend even more time doing paperwork that would have been better spent treating patients.
- Instead of treating patients, physicians will have to spend their time fighting the likes of Aetna and Cigna for just reimbursement.
- Aetna and Cigna are putting patients in the middle of a claims tug-of-war.
- Aetna and Cigna are using mysterious, opaque algorithms to second-guess the clinical judgment of the physicians that patients trust — and refusing to explain or justify their decisions.
Effect on Independent Physicians
- Independent practices lack the armies of coders and administrators that hospital systems have. They don’t have the capacity to play insurers’ bureaucratic games.
- Downcoded claims necessitate time-consuming appeals and effectively force practices to beg for payment for the care they’ve provided.
- A policy of automatic underpayment strains independent practices’ scarce resources.
- And by threatening independent practices’ financial viability, these policies hasten consolidation within the healthcare market.
- To avoid these administrative and financial headaches, independent practices accede to buyout offers from large hospitals and health systems.
- Such consolidation results in higher costs, fewer choices, and less personalized care for patients.
Backward Policy
- Both policies flout coding guidelines from the American Medical Association and the Centers for Medicare and Medicaid Services, which require review of medical records to determine visit complexity.
- Aetna and Cigna’s approach is opaque. Physicians do not know the criteria or algorithms being used, leaving them unable to avoid downcoding even if they code correctly.
- These actions may even conflict with federal and state law, including prompt-pay requirements and fair claims review standards.
Please find policies linked below: