I'm an RCM Expert. I Just Became a Patient Statistic in the UNC-Cigna Dispute.

revenuequestllc
2 days ago
12 min read

Published: October 27, 2025

Last Updated: October 27, 2025

Author: Marketta Burrell, CRCP

Company: RevQuest LLC

Important Disclaimer: This content is provided for educational and informational purposes only and does not constitute legal, medical, or professional advice. Healthcare compliance requirements can vary by state, payer, and type of practice. Readers should consult with qualified healthcare attorneys, compliance professionals, and their professional advisors before implementing any compliance strategies discussed in this article. RevQuest LLC does not provide legal advice and recommends working with qualified legal counsel for specific compliance guidance.

A Cigna Healthcare letter dated October 16, 2025. — The letter from Cigna Healthcare is dated October 16, 2025. I'm one of 60,000+ North Carolina residents who received this notification that UNC Health may be out-of-network by December 1st.

On Saturday, October 25, 2025, as a patient, I opened my mail to find a letter from Cigna Healthcare dated October 16, 2025. The letter informed me that UNC Health, my healthcare system, may no longer be in-network as of December 1, 2025. This gives me barely five weeks to figure out my care options.

Unless a new agreement is made, UNC Health will be out-of-network for Cigna commercial plans starting December 1. I, like over 60,000 other North Carolinians, have just over five weeks to find a new primary care provider.

It's not because I'm moving

It's not because my doctor is retiring.

It's because my insurer and my health system couldn't agree on a contract.

What makes this situation unique is that I'm not just a patient.

I'm a revenue cycle strategist. I've spent 23 years in medical billing, reimbursement, and compliance. I hold the CRCP certification. I've helped hospitals and clinics respond to denials, negotiate payer contracts, and manage coding accuracy.

I also founded RevQuest LLC™, a company that helps healthcare providers recover and protect their revenue. And I created Revenue Reset™ and Downcoding Defense™ tools built specifically to help practices survive payer audits and policy shifts like Cigna's R49.

Despite my considerable expertise, I am currently unable to find a primary care physician in North Carolina who is accepting new patients.

As I sit here with this letter, experiencing this crisis from both sides, I see something most people are missing. The UNC Health–Cigna dispute isn't really about one contract. It's a symptom of a healthcare system reaching its breaking point.

Here's what I see from both perspectives and why this should terrify every healthcare provider in America.

The Provider Perspective — What I Know Professionally about the UNC-Cigna Dispute

I've collaborated with providers for over two decades. I've seen what happens when policies like R49 are introduced first quietly, then aggressively, and what it does to healthcare practices trying to stay solvent while still caring for patients.

So let me break this down clearly: UNC Health's decision to walk away from Cigna wasn't made lightly. It's the result of multiple pressures colliding at once.

1. Prior Authorization Overload

Cigna, like many payers, has steadily increased its use of prior authorizations.

It's not only for MRIs anymore. It's routine labs. It's medications. It's specialty visits.

And each authorization comes with delays, follow-up phone calls, peer-to-peer reviews, and staff time that doesn't show up on a claim form.

This creates a direct burden on clinicians and administrative staff. The workload increases, but the reimbursement does not.

2. Inadequate Reimbursement That Is Eroding Year After Year

What payers don't say publicly is that many rate increases haven't even kept up with medical inflation.

Meanwhile, claim-level adjustments are accelerating, downcoding, bundling, denials for "not medically necessary," and documentation reviews.

It creates the illusion of stability, but the actual dollars collected per visit keep shrinking.

And when providers do get paid? Patients are often footing most of the bill.

Nine times out of ten, it's not the insurer absorbing cost, it's the patient through deductibles and coinsurance.

3. Escalating Administrative Costs

Every payer has its own set of rules, and they change constantly.

Practices now need entire teams just to keep up with:

Documentation compliance
Modifiers and NCCI edits
Timely filing limits
Fax-based reconsideration forms (yes, still in 2025)

The cost of understanding and executing against each payer's playbook is rising sharply, and those costs are not reimbursed.

A clinic might need to hire an extra coder or authorization coordinator just to stay afloat under Cigna's policies alone.

4. Razor-Thin Margins = Breaking Point

All of this leads to what every CFO, practice manager, and physician leader understands intuitively:

You can't deliver high-quality care, meet regulatory expectations, absorb policy shifts, and grow your practice when you're operating on 3% margin and losing 10% of your claims to silent adjustments.

That's where UNC Health likely is now.

Yes, they're negotiating. Yes, they're asking for more money. However, they're also trying to protect their clinicians, keep staff employed, and avoid compromising patient care.

Nevertheless, when Cigna downcodes Level 4 visits to Level 3 or delays authorization on a routine infusion, it's not just a billing issue.

It's an existential one.

The Patient Perspective — What I'm Living Personally

As a patient, I received a letter dated October 16, 2025, from Cigna. I didn't open it until October 25.

In that letter, I was told that UNC Health, my healthcare system, may no longer be in-network as of December 1, 2025. That gives me barely five weeks to figure out what to do about my care.

And here's the line that hit me hardest:

"For continuity of care, you may be eligible for a special program after December 1."

Eligibility to be determined. Let me be clear: that's not reassurance. That's a maybe.

What Continuity Looks Like in Real Life

Do I have ongoing care needs? Yes.
Do I have a specialist tied to my current PCP? Yes.
Do I have time to start over? No.

Now I may have to:

Call a new clinic and hope they're accepting new patients.
Transfer medical records and hope they arrive in time.
Wait weeks or months for an intake appointment.
Hope the new provider can pick up where my current one left off.

Meanwhile, prescriptions, referrals, and follow-ups could get delayed or denied.

And none of that is because of my health status; it's because of a contract negotiation I had no part in.

The Emotional Reality of Being a Statistic

I fully grasp how this works. I'm well-versed in payer strategies, contract language, and the revenue implications. However, I didn't anticipate experiencing this level of disruption in my own care.

I'm frustrated. I'm anxious. And I'm angry not at one side or the other, but at a system that routinely turns patients into collateral damage.

And I'm just one person. Over 60,000 North Carolinians are facing this same uncertainty right now.

Some of them are pregnant. Some are immunocompromised. Some are undergoing cancer treatment.

And they're being told: "We'll see if you qualify for continuity of care. Check back after December 1."

This Isn't a Hypothetical Anymore

It's not a policy on paper.

It's my actual health coverage.

At this moment, it's unstable.

What Both Sides Are Missing

UNC Health and Cigna have both made their positions clear in letters, in statements, and in the media.

Having been involved in the payer-provider relationship and now directly impacted, I can say that both parties are overlooking the bigger picture.

Cigna's Position:

"UNC is asking for too much money."

"We're protecting affordability for patients."

"UNC's rate hike request would drive up healthcare costs."

What Cigna Won't Say:

Their own downcoding policies (like R49) are already reducing payments.
Their prior authorization rules create hidden costs for providers.
Their administrative demands force practices to absorb the burden or walk.
Patients aren't protected; they're redirected. And redirected doesn't mean protected. It means disrupted, delayed, or denied entirely.

Cigna frames this as defending the patient. But patients like me are now scrambling to stay connected to care and facing "eligibility" reviews only to continue seeing our doctors.

UNC Health's Position:

"We need fair reimbursement."

"We're fighting for care quality."

"Cigna is making it impossible to sustain operations."

What UNC Won't Say:

By walking away, they're leaving 60,000+ patients in limbo.
Patients didn't cause this, but we're the ones holding the consequences.
UNC could have invested in stronger revenue cycle systems to improve efficiency before things reached a breaking point.
And they're using this very public dispute as leverage, and yes, that includes patients as bargaining chips.

UNC frames this as a stand for quality.

But from a patient's view, it's hard to feel protected when I'm being pushed out-of-network just in time for cold and flu season.

The Truth Neither Side Will Acknowledge:

This isn't just a contract breakdown.

This is a systemic failure of the reimbursement model.

Downcoding is bleeding providers dry.
Administrative load is crushing small practices.
Patients are absorbing the fallout — financially, logistically, and emotionally.

Cigna thinks it's saving money. UNC thinks it's standing up for care. But in the middle, there is a broken process that neither side wants to fix because it doesn't affect them the way it affects us: the practices, the frontline teams, and the patients.

Why This Is Happening Everywhere

What's happening between UNC Health and Cigna Healthcare isn't a one-off contract dispute. It's not local. It's not isolated.

It's part of a national pattern that's becoming impossible to ignore.

This Isn't Just About Cigna

Duke Health vs. Aetna — another North Carolina system at odds with a national payer.
WakeMed vs. UnitedHealthcare — also in NC, with tens of thousands of patients caught in the middle.
Sutter Health (CA), Allina (MN), NorthShore (IL), and Mount Sinai (NY) — all have had payer contract breakdowns in the last two years.

The common thread: provider systems reaching a breaking point with reimbursement pressure, administrative volume, and payer-driven control over clinical decision-making.

The Pattern We Keep Seeing:

Payers implement cost-control policies. (Downcoding. Prior authorizations. Medical necessity denials. AI-assisted reviews.)
Providers absorb those cuts. (Margins shrink. Staff burnout increases. Revenue gets squeezed.)
Contract negotiations get ugly. (Rate increases requested to cover the shortfall.)
Someone walks away. (Usually the provider, because the payer has more leverage.)
Patients suffer. (Being in-network no longer exists. Referral delays. Disrupted care continuity.)

And R49? That's not the cause. It's the accelerant.

It didn't start the fire, but it poured fuel on an already smoldering system.

Why It's Accelerating Now

Payers are under pressure to contain costs as employer plans, ACA contracts, and Medicare Advantage rates tighten.
Providers are fatigued; they've stretched, adapted, and documented everything short of blood types just to get paid.
Technology makes it easier for payers to automate claim edits and denials, and harder for practices to keep up.
Patients are becoming more vocal but less empowered about continuity of care and surprise billing risks.

What we're seeing with UNC and Cigna is just the latest flare-up in a national trend. And it won't be the last.

The Solution Nobody's Talking About

Here's the part that gets left out of every news story, every press release, and every payer/provider statement:

The revenue cycle is broken. And no one is fixing it.

We keep blaming payers. We keep defending providers. However, the true shortcoming lies in the infrastructure and the unwillingness to modernize, standardize, and proactively protect revenue.

What I Learned Building Downcoding Defense™

When I built Downcoding Defense™, it wasn't just about templates or codes.

It was about creating a system of protection for the dollars that fuel care and the practices being forced to play defense every single day.

Here's the truth:

Most providers don't know they're being downcoded until revenue starts shrinking.
Most documentation gaps are preventable, but only before the claim goes out.
Most appeals never happen because the infrastructure to respond isn't built.
Most revenue erosion is silent and permanent.

The Reason I Built Downcoding Defense™ Originally for R49:

I saw this coming.
R49 was just the beginning.
The downcoding problem is universal.
Providers needed defensive infrastructure — now, not later.

Then I Expanded It to All Payers:

Because R49 isn't the real threat.
Systemic downcoding across all payers is.
And providers need protection everywhere, not just when the headlines hit.

That's why I built the system not as a reaction, but as preparation. Learn how Downcoding Defense™ works →

If more organizations had this infrastructure in place, they might not have to walk away from payer contracts only to survive.

And patients like me wouldn't be left scrambling to find a new doctor with five weeks' notice.

That's why Downcoding Defense™ exists — now part of the Revenue Reset™ system: to give providers the tools to stay in-network profitably, so patients don't become collateral damage.

What Providers Should Do NOW

This isn't a time for panic — but it is a time for preparation.

Whether your organization is renegotiating with Cigna, UnitedHealthcare, Aetna, or any major payer, here's what you should be asking right now:

Do we know how much revenue we're losing to downcoding?
Can we prove our documentation supports our coding levels?
Do we have workflows and staff ready to respond to payers' policy changes?
Are we tracking administrative burden and its financial impact?
Do we have data that informs decisions, or are we reacting emotionally?

You don’t have to fight downcoding alone. Revenue Reset™ offers real-time risk scoring, documentation support, and payer-specific appeal tools built to defend your margins.

📊 Calculate Your E/M Revenue Impact Score

📥 Book a 1:1 Strategy Call

Before you terminate a contract, audit your exposure:

What are you losing in actual dollars to denials and downcoding?
How many staff hours are spent on payer-specific administrative tasks?
Could better infrastructure reduce that burden enough to stay in-network profitably?
Are your decisions based on financial models or frustration?

The UNC–Cigna dispute teaches us this:

Contract disputes are becoming common.
Walking away disrupts patients.
Staying without protection is unsustainable.

There's a third option: Build revenue cycle defenses before the crisis hits.

Organizations that implement proactive downcoding detection, pre-bill validation, and centralized appeals processes aren't just protecting margins; they're preserving patient access.

That's the decision in front of every healthcare leader right now.

I Hope I Find a Good Doctor

As I write this, I have 36 days to find a new primary care physician in North Carolina.

I understand why UNC Health is doing this. As an RCM professional, I get it.

But as a patient, I'm frustrated, anxious, and honestly angry that I'm collateral damage in a fight that didn't have to happen this way.

The healthcare system is broken. Payers are squeezing providers. Providers are walking away.

Patients are suffering.

This issue will persist unless we tackle the fundamental cause of systematic revenue decline due to downcoding and administrative burdens.

I built Downcoding Defense™ to help prevent these crises. I only wish more providers had tools like this before they reached the breaking point.

If you're a healthcare provider watching the UNC–Cigna situation and thinking "that could be us next year," you're probably right.

The question is: What are you going to do about it?

You can start by exploring Revenue Reset™ tools or talking with a RevQuest LLC recovery strategist today.

📥 Book a Strategy Call · Run a E/M Revenue Impact Score · Explore Revenue Reset™

Cigna Healthcare is a registered trademark of Cigna Intellectual Property, Inc. References to Cigna Healthcare’s R49 policy are for informational and educational purposes only. Revenue Reset™ and RevQuest LLC™ are independent entities and are not affiliated with or endorsed by Cigna Healthcare or any other payer referenced.

About the Author

Marketta Burrell, CRCP, is the founder and CEO of RevQuest LLC™ and creator of Revenue Reset™ and Downcoding Defense™. With over 23 years of healthcare revenue cycle management expertise, she specializes in helping providers protect revenue and navigate payer policy changes. She is also one of 60,000+ North Carolina residents currently affected by the UNC Health-Cigna contract dispute.

You don't have to face payer pressure alone. RevQuest LLC™ and Revenue Reset™ are here to support you — from strategy to systems to survival.

📚 Sources & Further Reading

National & Local News Coverage

UNC Health–Cigna Contract Dispute and Patient Impact UNC Health Newsroom (July 1, 2025) https://www.unchealthcare.org/newsroom/2025/unc-health-contract-update-cigna
“UNC Health’s current, three-year agreement with Cigna expires on Nov. 30, 2025. If UNC Health doesn’t reach a new and fair agreement, all Cigna commercial plans will be considered out of network beginning Dec. 1, 2025.”
60,000+ North Carolinians Potentially Affected Axios Raleigh (October 2025) https://www.axios.com/local/raleigh
“If the two do not come to an agreement by Nov. 30, then more than 60,000 Cigna members who use UNC Health could become out of network…”
Similar Contract Disputes (Duke, WakeMed, etc.) WRAL News https://www.wral.com
“Duke Health and Aetna are involved in a contract dispute… WakeMed and UnitedHealthcare also faced a similar breakdown earlier in the year.”

Payer Policy & Industry Trends

Cigna R49 Policy (Downcoding of E/M Codes) California Medical Association (CMA) https://www.cmadocs.org/newsroom/news/view/ArticleId/50421/Cigna-to-Delay-Downcoding-Policy
“The policy... allows Cigna to automatically downcode higher-level E/M services whenever the plan determines documentation doesn’t support the level billed.”
Administrative Burden & Prior Authorization Trends MGMA Stat Report (2023) https://www.mgma.com
“Utilization management tools, such as prior authorization, not only delay patient care but also increase provider costs and burden.”
National Patterns of Downcoding and Provider Impact Oncology News Central https://oncologynewscentral.com/articles/downcoding-practices-by-payers
“Health plans are downcoding claims using undisclosed algorithms, often without reviewing clinical documentation to verify whether the services are justified.”

RevQuest LLC Blog Citations (Internal Sources)

Understanding Cigna’s R49 Policy: A Critical Update for Providers RevQuest LLC Blog — September 24, 2025 https://www.revquestrcm.com/post/the-hidden-strategy-behind-cigna-s-r49-downcoding-policy
“Even small changes in how high-level E/M codes are evaluated can create significant revenue disruption for outpatient-heavy practices.”
The First Week of Cigna R49: What Practices Are Seeing Already RevQuest LLC Blog — October 3, 2025 https://www.revquestrcm.com/post/the-first-week-of-cigna-r49
“Within days of implementation, providers reported auto-downcoding of Level 4 visits — often without documentation requests.”
The Silent Downcoding Trend: Why It’s No Longer Just About Cigna RevQuest LLC Blog — October 16, 2025 https://www.revquestrcm.com/post/the-silent-downcoding-trend-why-it-s-no-longer-just-cigna
“R49 is now a signal of wider change — other payers are watching and replicating the approach, putting more pressure on provider margins.”