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On Oct. 1, Cigna will roll out a policy that tracks how physicians bill. It will flag those who submit a higher proportion of level four or level five visits — which get reimbursed at a higher rate — than their peers. For doctors placed under this extra scrutiny, certain claims at those higher levels may be adjusted down by one level if the billing details do not appear to justify the service. The affected codes include 99204–99205 (new patient, office/outpatient), 99214–99215 (established patient, office/outpatient), and 99244–99245 (consultations).
Cigna says the goal is to fight upcoding and billing abuse, arguing that some physicians bill for more complex visits than were actually provided, such as charging for a 40-minute encounter when the visit lasted only 10 minutes, and that these patterns drive unnecessary costs for patients and employers.
But coding is not based on time alone. Under current rules, physicians can bill according to either total time or the complexity of medical decision making. That means a physician who legitimately spends half an hour or more untangling multiple conditions, reviewing medications, and coordinating care could still be flagged as an outlier, triggering payment reductions and extra administrative work even when the documentation supports the higher code.
While many physicians groups are saying that the downcoding will happen automatically, Cigna denied it, telling STAT the new policy is “an additional layer of review for this small subset of claims and providers.” Without more detail, though, I remain concerned. Even if it’s not automatic yet, this is a step toward it.
Complexity in medicine cannot be reduced to a billing code. A patient with hypertension, diabetes, or depression may look “routine” on paper, yet the visit may involve reconciling medications, coordinating referrals, addressing side effects, screening for complications, and navigating barriers like cost or insurance approvals. That is not a three-minute problem; it’s a 30 to 40-minute conversation.
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Even something as straightforward as prescribing an antibiotic for strep throat illustrates the flaw. To the insurer, it may look like a “simple” diagnosis. In reality, it requires confirming the diagnosis, counseling on medication use, reviewing allergies, considering complications like rheumatic fever, updating preventive care, and documenting the encounter. That is a 99214 visit, even though the diagnosis itself appears uncomplicated.
By tying reimbursement to diagnosis codes instead of the actual clinical work performed, this policy devalues physicians’ time and judgment. It assumes that complexity exists only in “rare” or “severe” codes, when in truth, outpatient medicine is full of nuance that cannot be captured by a single label. The result is a distorted view of patient care that punishes doctors for doing their jobs thoroughly — and ultimately undermines the quality of care patients receive.
Under this policy, a fully documented, clinically appropriate high-level visit could be reimbursed as a lower-level visit, with payment reduced accordingly. The only way to restore payment is through an appeal requiring resubmission of the entire medical record. In practice, this is not a neutral “review” — it is downcoding based on Cigna’s own definition of what qualifies as “complex,” a standard that fails to reflect the realities of patient care.
This is not a minor adjustment. It is the start of a slippery slope. What stops others from following? What begins with applying extra scrutiny to complex office visits could eventually expand to procedures, imaging, or lab interpretations. Over time, insurers — not physicians — may determine how medical work is valued.
At first glance, downcoding might sound like a technical tweak. In reality, it creates a crushing administrative burden. Each downcoded visit will surely trigger a full appeal: pulling charts, re-coding, resubmitting, and waiting. Large health systems may absorb this with billing staff. Smaller independent practices cannot. Appeals already clog the system, and a new approach to downcoding risks further backlogs.
Most damaging of all, when a visit is fully documented yet still reduced, it sends the message that physician judgment and time are undervalued. We’ve seen this pattern before. Prior authorizations were once a narrow tool to contain costs. Step therapy was billed as a safeguard. Today both consume vast amounts of physician time and, in the case of prior authorizations, sometimes delay lifesaving care.
One of my patients was recently diagnosed with a deep vein thrombosis — a dangerous blood clot in the leg. I prescribed Xarelto, a commonly used anticoagulant. The insurance company denied coverage. For several days, the patient went without medication while we scrambled to secure samples of Eliquis and a prior authorization was processed. This is unacceptable. It is a stark reminder that every layer of red tape doesn’t just create paperwork — it puts patients at risk.
Cigna’s new downcoding policy carries the same danger. What begins as one company, one policy, and one set of codes could quickly become an industry standard.
The problem is hitting a system already breaking under bureaucracy. A 2016 study in the Annals of Internal Medicine shows physicians spend nearly half of their working hours on administrative tasks. Burnout is at record levels, with more than 60% of physicians reporting symptoms, according to the Annals study. The leading cause is not patient care — it is paperwork.
The U.S. also faces a looming physician shortage, with projections of up to 86,000 fewer physicians by 2036. Every new requirement accelerates retirements, pushes physicians into nonclinical roles, or reduces patient-facing hours. At a moment when we need more doctors in practice, downcoding adds weight to an already overloaded system.
Patients will feel the impact most. When physicians are buried in paperwork, patients wait longer for appointments. Administrative overload chips away at time for communication, follow-up, and coordination. Many small practices will struggle to keep up, pushing them toward closure or consolidation. Larger systems often bill at higher rates, driving costs up. Delays caused by administrative barriers can worsen conditions, leading to more ER visits and hospitalizations. Every hour spent resubmitting claims is an hour not spent with patients.
Oversight has a role in health care. Fraud and abuse must be addressed. If physicians consistently overcode, they should be reviewed, audited, and corrected. No physician objects to that. But expanded downcoding is not balanced oversight. It sweeps in the majority who code correctly alongside the minority who may not. It shifts the cost of policing onto every practice, regardless of accuracy. And it creates no benefit for patients. Care does not improve. Access does not expand. Safety does not increase. What it does is reduce reimbursement, slow payments, and add paperwork.
There are better paths. Focus reviews on true outliers rather than penalizing all physicians. Share the criteria for review list placement and appeal outcomes. Make corrections automatic when documentation is present, rather than requiring full resubmission. Work with physician organizations to design oversight that reduces abuse while respecting clinical judgment. These solutions protect resources without adding unnecessary barriers for patients and physicians.
Physicians are not asking for a system without oversight. We are asking for balance — for policies that recognize the trade-offs of every added burden. Oversight that preserves resources but does not erode patient care. Medicine is already complicated. We should be working to simplify it, not layer on more red tape.
As this policy takes effect, we need to ask a simple question: Does it make care better, or does it simply make care harder? If it’s the latter, we are sliding down a slope that leads to fewer physicians, longer waits, higher costs, and worse outcomes.
Ryan Nadelson is chair of the Department of Internal Medicine at Northside Hospital Diagnostic Clinic in Gainesville, Ga., and an author on physician identity, leadership, and the humanity of medical practice.