By David Eagle
Two large health insurers are trying their hand at a different profession – the practice of medicine.
Aetna and Cigna have announced that they may unilaterally “downcode” some types of care – and pay physicians less than what patients’ conditions would ordinarily warrant.
The two insurers are effectively overruling physicians’ clinical judgment and lining their pockets in the process. Patients will pay a steep price. By squeezing independent physicians’ finances – and forcing them to go through arduous appeals processes to claim just reimbursement – Aetna and Cigna could soon make it more difficult for Americans to find timely, affordable care.
Here’s how this downcoding scheme works. Aetna and Cigna have claimed the right to decide that a patient’s care was less complex than what that patient’s own physician determined after actually providing service.
If the insurers “downcode” the claim in this way, they pay the physician at a lower rate for what they claim should have been less complex care. If physicians disagree, they need to provide supplemental documentation and go through an appeals process to contest the lower payment.
These new rules apply to certain Evaluation and Management (E/M) services – which include everything from preventive visits to the doctor to hospital visits and home services. In these cases, any time a doctor deems a patient’s needs to be either level 4 (moderately complex) or level 5 (highly complex), the health insurer says it has the right to ratchet the level down – without reviewing the patient’s medical record.
That means the insurer is basing its decision solely on the claim form – a document that includes only billing codes and brief descriptions and lacks the detailed information needed to determine the proper E/M code level of care.
This downcoding is guided not by expert physician judgment but by blind algorithms. It happens without any review of patient medical records – a direct contradiction to guidelines from the American Medical Association.
Second-guessing doctors as a matter of policy is not just an inappropriate assault on physician autonomy but also at odds with the data. A 2024 Medicare audit found that just 0.13% of claims for two of the most frequently billed E/M codes were incorrect.
More worrying are the implications for patients. These downcoding policies will force doctors out of the exam room and onto the phone and computer, where they’ll have to defend their original assessments against insurers’ revisions. That will leave them with less time to see patients.
Even in cases where physicians successfully defend their original assessments, the resulting delays in payment could stretch practices to a financial breaking point.
Some may respond by leaving independent practice. For years, physicians have responded to mounting administrative burdens by selling their practices to larger entities, including hospitals and health systems. Between 2019 and 2024, hospitals acquired 7,600 physician practices.
Such consolidation gives large healthcare organizations enormous power to determine not only the cost of care but also where and when patients can receive it. A recent study published in JAMA Health Forum found that prices for office visits with hospital-affiliated primary care doctors were 11% higher than at unaffiliated practices.
Aetna and Cigna’s new policies will exacerbate the consolidation fever that has gripped the healthcare market. In the end, patients will find it harder to get timely care from a physician of their choosing – and at a reasonable price.
These insurers aren’t just interfering in the medical decisions of trained physicians. They’re jeopardizing access to care for millions of Americans. Until these insurance behemoths roll back their outrageous policies, the integrity and availability of medical care in this country will remain under needless threat.
Dr. David Eagle is a board-certified hematologist-oncologist and president of the American Independent Medical Practice Association (aimpa.us).