The Maryland Insurance Administration has fined Cigna $80,000 and ordered the insurer to halt its use of automatic downcoding for certain evaluation and management (E/M) claims, citing violations of state law and concerns over payment delays.
Cigna’s policy allowed adjustments to higher-level E/M codes—such as 99204–99205, 99214–99215, and 99244–99245—if documentation did not meet specific complexity criteria. However, regulators determined that instead of automatically reducing claim levels, insurers must formally dispute questionable claims and request additional documentation from providers.
The decision comes amid broader scrutiny from medical societies, including Maryland State Medical Society, which has raised concerns about the impact of downcoding on reimbursement, administrative burden, and provider stability. Critics argue the practice can undermine clinical judgment and delay appropriate payment for care.
While Cigna maintains that its policy aligns with industry guidelines and affects a small percentage of providers, it has agreed to comply with Maryland’s directive. The move reflects a growing regulatory focus on payer practices related to claims editing and reimbursement—an area providers should continue to monitor closely as similar policies emerge nationwide.
Resource: Maryland fines Cigna $80K, demands halt to automatic downcoding