Latest Update on NC Health Insurance Payers Implementing Downcoding Claims Review Programs
The NCMS recognizes several health insurance companies have recently implemented claims and code review programs resulting in the down coding of certain Level 4 and 5 Evaluation and Management (E/M) claims.
Our leadership team met with representatives from Aetna sharing concerns about the significantly negative impact their program has on physician practices in our state. Aetna representatives shared their “Evaluation and Management (E&M) Program Claim and Code Review” does not target all Level 4 and 5 E&M codes nor include all providers in the state. While we are aware of the participation details and how providers are identified and placed in the program, there is still confusion about the applicability and reason for its implementation. NCMS has requested clarification and will continue working with representatives.
Cigna’s “Evaluation and Management Coding and Accuracy Program” takes a more sweeping approach applying to all physicians but limiting their review to six codes: 99204-99205 (new patient), 99214-99215 (established patient) and 99244-99245 (consult for new & established patients). This program is to be implemented nationally on 10/1/2025. The AMA and several state and specialty societies are working together to address this with Cigna. NCMS staff is working to meet with Cigna leadership. For questions or comments, please contact Jenni Hines, Director of Payer & Practice Engagement at [email protected]. NCMS remains committed to resolving this issue.
If you find yourself included in Aetna’s claims review program and don’t agree with their edits, please follow the appropriate appeals process to ensure issues are addressed in a timely fashion. Note, some contracts have special dispute provisions – please make sure you know your options.
Please tell me there is a class action suit in the works.
yes class action please!!
This is just stealing money from us. They know most of us don’t have the time or the staff to fight these types of policies. It is shameful that insurance companies can get away with this type of thing. You can’t go to your hairdresser, get a cut and color and then just pay for the cut and expect the hairdresser to be okay with it. We need to be paid for the work we do.
The burden then gets put on us to appeal and argue with the denial/downcode. This is especially eggregious since they are not even looking at the note. This is just capricious and abusive behavior. Essentially, Aetna and Cigna are flexing their clout and indicating that they expect their behavior to stand without meaningful challenge.
For those of us in cognitive specialities, this is particularly hard hitting. The CMS add on code for complexity is not being reimbursed at all by these same payors. So CMS recognizes that we are being underpaid with traditional E/M for complex payors and offers an add on code to use. These payors do not recognize that code and do not pay it; and now, they are also going to downcode Level 4/5 so that they can keep even more of the premiums we are ALL paying.
Class action lawsuit absolutely required. They have become shamelessly emboldened to take the most unethical and abusive actions they can.
This is an egregious usurpation of physician decision-making, autonomy, and independence. NCMS and the NC Department of Insurance need to act upon this misguided money-grab ASAP. Independent practices without an army of coders and billers cannot withstand yet another financial hit from insurers in the face of Medicaid and Medicare cuts as well as the failure of CMS reimbursement to account for – much less keep up with – inflation over the last 15 years. This is nuts!