The Maryland Insurance Administration issued Cigna an $80,000 fine and is requiring the insurer to stop automatic downcoding under a recent policy, according to a March 13 letter.
Cigna’s evaluation and management policy allows the insurer to adjust some higher-level E/M codes if they do not adhere to certain complexity standards. Codes 99204-99205, 99214-99215 and 99244-99245 fall under this umbrella.
Maryland regulators determined the policy is not allowed under state law. Regulators identified payment delays, as well. Instead, Cigna must formally dispute claims it believes to be improper and request further documentation.
Medical associations across California, Texas and Tennessee have questioned whether the “automatic downcoding” would pose a barrier to reimbursement or heighten administrative burden for providers. The Maryland State Medical Society, or MedChi, has previously accused Cigna, among other insurers, of underpaying providers.
“Downcoding is not a harmless administrative adjustment,” MedChi CEO Gene Ransom said in a March 17 statement. “It undermines physician judgment, delays payment for legitimate care and ultimately harms patients by destabilizing the physician practices that care for them.”
Cigna said its E/M policy aligns with AMA guidelines and only affects around 1% of in-network physicians.
“We continue to believe that appropriate coding and reimbursement are important to protect Americans against potentially improper or inflated bills, which contribute to the healthcare affordability crisis,” a Cigna statement shared with Becker’s March 20 said. “Consistent with the Maryland Insurance Administration’s guidance and in compliance with Maryland law, we will continue limited reviews of certain claims to help ensure customers are protected from improper billing.”
Cigna is not alone in its efforts to rein in E/M coding. On March 16, BCBS Illinois became one of the latest insurers to introduce tighter E/M claims editing and review procedures.
Becker’s contacted MedChi and will update this story if more information becomes available.
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