Despite Cigna launching its downcoding policy on Oct. 1, the insurer is temporarily holding off on implementing it for California HMO plans, according to the California Medical Association and Cigna.
The policy allows Cigna to adjust some higher-level evaluation and management codes if they do not meet certain complexity standards. Codes 99204-99205, 99214-99215 and 99244-99245 fall under this policy. After receiving questions over its legality, the reimbursement policy is awaiting review by the California Department of Managed Health Care.
“This approach also introduces avoidable friction with physician practices into the process, erodes trust between providers and plans, and exacerbates the challenges of delivering high-quality care in a resource-constrained environment,” the California Medical Association wrote in a letter to Cigna.
“Our new policy that ensures the limited number of impacted physicians are reimbursed appropriately for E/M services took effect as planned, with the exception of California HMO plans regulated by the state Department of Managed Health Care,” a Cigna spokesperson told Becker’s. “We anticipate that the policy will also take effect for these plans’ claims in California after the DMHC completes its review of the additional information that we have provided.”
The insurer previously clarified which providers would undergo greater scrutiny, according to the Texas Medical Association. Cigna estimated that more than 97% of providers who frequently bill level 4 and 5 codes would not be affected. Affected providers can also request a review of any automatic changes, according to Cigna.
The California and Texas medical associations were among the organizations that had pushed back against the policy. After the Texas group expressed its concerns, Cigna told the organization the policy is “intended to place additional scrutiny only on claims billed by providers who[m] our records indicate as having a consistent pattern of coding at a higher [evaluation and management] level compared to their peers.”
Services for children under 1 year old, some transplants and other complex conditions will not be subject to this adjustment. The same goes for claims submitted by behavioral health providers.
