The Silent Downcoding Trend: Why It’s No Longer Just Cigna
- revenuequestllc
- Oct 16
- 6 min read
Updated: Oct 16
Published: October 16, 2025
Last Updated: October 16, 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.
When Cigna Healthcare's R49 policy made headlines in October 2025, many assumed it was an isolated case. Cigna Healthcare then paused the policy due to regulatory pressure. The relief was short-lived. The trend didn't stop; it had already spread to nearly every major insurer in the country.
New findings from the American Society of Clinical Oncology (September 2025) and an NBC News investigation (October 2025) reveal a troubling trend. Automatic downcoding has quietly expanded across nearly every major insurer in the United States. Aetna, Ambetter, Elevance (formerly Anthem), Blue Cross Blue Shield (NC, MA, TN), Humana, Kaiser, Molina, United Healthcare, and Wellcare have all introduced “coding accuracy” or “payment integrity” programs that use algorithms to reduce E/M levels automatically, often without reviewing clinical documentation, according to reports from NBC News, the American Society of Clinical Oncology, and healthcare policy analysts.
NBC News reported that some physicians lost between $3,000 and $14,000 in a single year before realizing their payments had been quietly adjusted.
These are not merely standard denials; they are subtle reductions cleverly concealed within ordinary claim cycles.
According to Rivet Health Law and NBC News, payers promote these automated programs to employers as tools that deliver about 6 percent cost reductions through 'coding accuracy' initiatives. This economic incentive explains why the practice continues to grow, despite widespread provider concern.
Automation: The New Gatekeeper of Downcoding
Many payers present these changes as measures for quality control. In practice, they rely on data models that compare provider billing patterns and downgrade any claim that appears to be an outlier.
High-level visits such as 99204 to 99215 and 99284 to 99285 are frequent targets.
Since these decisions occur within automated systems, providers rarely see clear reasoning. On the Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA), payers include short notes called remark codes that are meant to explain the adjustment.
In many downcoded claims, these notes are brief phrases such as “service level adjusted per policy.”
Others appear as two-digit or alphanumeric codes that sound routine, but carry a major financial impact.
For example:
CO-97 – Payment adjusted because this service was included in another service or payment already made.
56 – Procedure or treatment has not been deemed proven to be effective by the payer.
50 – These are non-covered services because the payer determined they are not medically necessary.
These codes appear on thousands of EOBs each day, often without explanation beyond these brief remarks. Most billing staff accept them as routine processing notes. However, each one can represent hundreds of dollars in lost revenue multiplied across dozens of claims per month.
To someone reviewing payments, these lines may look like standard explanations, but they often mean the payer’s system has automatically downgraded or denied a service before anyone has ever reviewed the clinical documentation. Without understanding these codes, a clinic might accept the payment as correct when it is not.
As automation replaces transparency, physicians are increasingly left to explain the inexplicable.
Why Oversight Came Too Late
National associations such as the AMA, MGMA, and AHA were not ignoring the issue; they simply could not detect it. Since no formal policy announcements were published, early downcoding appeared as random payment variance.
By the time enough data surfaced to reveal a pattern, providers had already absorbed months of underpayment. That lag is exactly why revenue awareness, not regulation, is the most practical protection right now.
A Lesson from a Urology Claim
Years before the term 'automatic downcoding' entered industry vocabulary, I witnessed this pattern emerging.
A urology clinic submitted a $10,000 surgical claim that was denied for a “documentation mismatch.” This example highlights the importance of accurate documentation in preventing downcoding. The operative note was clinically correct but lacked a few words that captured the case’s complexity.
I collaborated directly with the provider to clarify the documentation for accurate care and clearer language. The revised claim was paid in full within thirty days.
That experience exposed how payers’ systems read documentation. They do not interpret context; they scan for structure. What they cannot find, they devalue.
This experience laid the foundation for the Revenue Recovery Path™, a systematic approach to identifying and correcting these silent losses before they multiply.
How RevQuest LLC™ Puts the Revenue Recovery Path™ into Practice
At RevQuest LLC™, the Revenue Recovery Path™ is the core service framework that helps healthcare practices recover missed payments and prevent future ones.
It focuses on three awareness checkpoints:
Monitor for subtle changes in payment. Keep track of instances when higher-level Evaluation and Management (E/M) codes consistently receive lower reimbursement than expected.
Connect documentation and payer logic. Clarify how decision-making, time, and risk are described so algorithms interpret complexity accurately.
Transform reactivity into prevention. Use monthly payer-pattern reviews and provider education to close the communication gap between clinical intent and claim interpretation.
This is not an audit but a continual awareness process that keeps compliant revenue visible, measurable, and defendable.
Where Revenue Reset™ Fits In
While RevQuest LLC™ manages recovery and process alignment, Revenue Reset™ gives providers and billing teams the ability to take these same concepts and apply them independently.
Its digital resources, including the Downcoding Defense™ templates and payer-communication tools, make the Revenue Recovery Path™ accessible and available on demand.
The two brands work together:
RevQuest LLC™ strengthens revenue operations for clinics that want partnership and active management.
Revenue Reset™ equips teams that prefer to handle improvement internally.
Both share the same goal: helping providers protect compliant revenue in a system increasingly driven by automation.
The Takeaway
Automation is not the enemy; rather, opacity is. If payer algorithms can downgrade claims silently, providers must be just as proactive in reading their own data.
Awareness is no longer optional; it is strategic protection.
If you are noticing payment levels that do not align with your documentation, it may be time to review your own Revenue Recovery Path™ and explore how educational tools from Revenue Reset™ can strengthen the connection between documentation and payment.
What You Can Do This Week:
Pull your last 90 days of EOBs and ERAs.
Search for these remark codes: CO-97, 56, 50, and any mention of 'service level adjusted'.
Calculate how much revenue was reduced without your knowledge.
Use our E/M Revenue Impact Calculator to estimate your annual exposure.
Then decide, will you wait for the next 'adjustment,' or will you build your Revenue Recovery Path™ now?"
In a healthcare system increasingly driven by automation, proactive revenue awareness is essential. Clarity is the new compliance, and awareness is the first 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 Revenue Reset™, bringing over 23 years of healthcare revenue cycle management expertise to compliance consulting. As a Certified Revenue Cycle Professional (CRCP) through AAHAM, Marketta has specialized in denial management, revenue cycle management, A/R recovery, and regulatory compliance across multiple healthcare settings, including physical therapy, hospitals, skilled nursing facilities, and specialty practices.
Her hands-on experience as Business Office Manager includes managing compliance requirements at Bluegrass Physical Therapy for six years, reducing aged A/R by 60% at specialty practices, and recovering over $55K in complex claims before timely filing deadlines. Marketta's Revenue Reset™ methodology has helped healthcare practices navigate regulatory changes while maintaining operational efficiency and financial stability.
Sources & Further Reading
American Society of Clinical Oncology. (September 22, 2025) What Cancer Care Providers Need to Know About Payer Downcoding.
NBC News. (October 9, 2025). Guilty Until Proven Innocent’: Doctors Say Insurers Are Downcoding Their Claims.
Rivet Health Law, PLC. (2025). New Cigna Policy Could Downgrade Your Claims — Without Warning. 2025.
AMA, MGMA, and AHA. (2023 - 2025). Statements on payer downcoding and coding accuracy programs.
Internal Case Experience (Urology Claim, Pre-RevQuest LLC™), 2016–2025. Documented and analyzed by RevQuest LLC™ for educational and research purposes.
Disclaimer: This content is for educational and strategic analysis purposes only and does not constitute legal, financial, medical, or business advice. Healthcare practices should consult with qualified legal, financial, and business advisors familiar with their specific circumstances, contracts, and local market conditions before making any strategic decisions regarding payer contracts or business operations.
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