What to Know About Cigna’s and Aetna’s New Downcoding Policies 

Cigna and Aetna are drawing provider backlash for new payment policies that reduce reimbursements. Cigna is automatically “downcoding” six Evaluation and Management (E/M) billing codes for a small percentage of providers, resulting in lower payments for routine services like office visits. Aetna’s new Medicare Advantage policy will automatically approve certain urgent hospital admissions but reimburse them at the lower observation rate instead of the full inpatient rate. Providers argue these opaque methods increase administrative costs and lead to underpayment. 

Implications for Urgent Care Centers

The new Cigna downcoding policy has a direct and negative impact on urgent care centers. 

1. Lower Revenue for Core Services: Urgent care primarily manages acute, low-to-mid complexity conditions like sore throats, ear infections, and minor injuries, which correspond to the E/M codes Cigna is targeting. If an urgent care center is flagged as an “outlier,” a significant portion of their routine claims will be automatically downcoded, directly reducing their total revenue per visit. 
2. Increased Administrative Burden: Being downcoded forces the urgent care center to dedicate more staff time and resources to appealing the payment for the higher original code. This adds significant administrative cost without a guarantee of success, effectively reducing the net profit per claim even further. 
3. Pressure to Code Lower: The policy creates a financial disincentive for providers to bill for the actual complexity of the patient’s visit, potentially leading to inaccurate billing practices or insufficient documentation efforts to meet the insurer’s demands, rather than clinical necessity. 

While the Aetna policy focuses on hospital inpatient admissions, the Cigna downcoding is a direct threat to the financial viability and operational efficiency of urgent care centers that rely on accurate E/M coding for their primary revenue stream.