Insurers are updating reimbursement policies that include new rules surrounding remote monitoring and inpatient reimbursement. Here’s a look at some of the most recent notable updates.
1. Cigna launched its downcoding policy on Oct. 1, which allows the insurer to adjust higher-level evaluation and management (E/M) codes for certain visits if they don’t meet complexity standards. This policy affects codes 99204-99205, 99214-99215, and 99244-99245. Cigna temporarily paused its implementation for California HMO plans while the California Department of Managed Health Care reviews the policy. The insurer clarified that over 97% of providers billing these higher codes will not be impacted. For affected providers, Cigna allows them to request a review of any automatic changes.
2. UnitedHealthcare will restrict coverage for remote physiologic monitoring in 2026, specifically excluding its use for Type 2 diabetes and most cases of hypertension. However, remote monitoring will still be covered for heart failure and hypertensive disorders of pregnancy. The new policy will apply to Medicare Advantage, commercial, individual exchange, and Medicaid members.
3. BCBS Massachusetts expanded its claims review process on Nov. 3 to target potential overcoding among providers who frequently bill for high-complexity visits (levels 4 and 5). The new policy will focus on a small subset of clinicians, with BCBSMA estimating that 1-2% of primary care physicians and 3-4% of specialists will be subject to the expanded review. Providers can submit additional documentation to appeal any reductions in reimbursement.
4. Elevance Health will penalize facilities using out of network providers under its Anthem Blue Cross Blue Shield commercial plans in 11 states starting in 2026. The penalty will be 10% of the allowed amount for claims involving out-of-network providers. However, emergency services and cases with prior approval will be exempt from the penalty.
5. Aetna introduced a new claims and code review program on Sept. 1, which applies to commercial, Medicare, and student members. The program may trigger medical record requests for certain claims, including high-dollar claims, implant procedures, anesthesia services, and bundled claims.
6. Aetna also rolled out its “level of severity inpatient payment” Medicare policy, set to begin in 2026 (originally scheduled for Nov. 15, 2025). The policy would approve urgent or emergent inpatient stays lasting at least one midnight but fewer than five, without a medical necessity review, and reimburse at a lower severity rate, aligned with observation services. Stays that meet Aetna’s supplemental guidelines for inpatient admissions will be paid according to the hospital agreement. Providers can request a severity review for stays that do not meet the policy’s criteria.
