Physician advocacy groups are urging Cigna to withdraw a new reimbursement policy that would automatically downcode high-level E/M claims, arguing it undermines clinical judgment and creates an unfair appeals process that will harm providers.
Cigna has announced a new reimbursement policy that will automatically reduce payments for certain high-level evaluation and management (E/M) claims, drawing sharp criticism from physician advocacy groups who claim the move is illegal and burdensome to providers.
Beginning October 1, the Evaluation and Management (E/M) Coding Accuracy Policy (R49) will apply to professional claims for level 4 and 5 E/M services. The policy allows the payer to unilaterally downcode claims by one level if the submitted diagnosis does not appear to support the complexity of the visit. To receive the originally billed payment, providers will be required to file a post-payment appeal with full medical records to justify the initial coding.
Physician advocacy groups, including the California Medical Association (CMA) and Texas Medical Association (TMA), have urged Cigna to retract the policy before it goes into effect.
The policy could run afoul of a California law that requires payers to disclose "detailed payment policies and rules and non-standard coding methodologies used to adjudicate claims," according to a statement from CMA.
The policy undermines physician expertise and the importance of medical record review, according to a statement from TMA.
"The cognitive work a physician performs to arrive at a diagnosis is not always reflected in the final diagnosis code," TMA President Jayesh Shah, MD, wrote in a letter to Cigna.
"A patient may present with a constellation of symptoms requiring extensive data analysis and risk assessment, only for the physician to rule out more serious conditions and arrive at a relatively simple diagnosis," he added. "This complex work is what the E/M code is meant to capture."
A New Burden for Revenue Cycle Teams
For revenue cycle leaders, the policy represents a significant new operational and financial challenge. The automatic downcoding will immediately reduce and delay cash flow for correctly coded claims. This will force staff into a reactive and burdensome appeals process to recoup the correct payment.
The inefficiency of the planned appeals process is a particular point of frustration. TMA says Cigna has not established an electronic submission method, which could leave providers to rely on fax machines to submit the required documentation. This creates a significant administrative hurdle that further delays payment and adds unnecessary costs to the revenue cycle.
Opponents of the strategy say Cigna may be expecting that busy practices will not have the time or resources to appeal every improperly downcoded claim, resulting in a net savings for Cigna. This approach, they say, undermines the clinical judgment of physicians and places yet another administrative obstacle in the path of provider financial stability.
Luke Gale is the revenue cycle editor for HealthLeaders.
KEY TAKEAWAYS
Effective October 1, 2025, Cigna's new policy will allow the insurer to unilaterally downcode level 4 and 5 E/M claims.
Physician groups have called the policy "unlawful," arguing that it violates fair payment laws and inappropriately uses diagnosis codes to determine visit complexity.
For providers, the policy is expected to reduce and delay cash flow while significantly increasing administrative burden.