Maryland orders Cigna to stop automatic downcoding, issues $80,000 fine 

Maryland’s Insurance Administration has fined health insurance company Cigna $80,000 and ordered the insurer to immediately stop its automatic downcoding of evaluation and management, or E/M claims, a move that underscores the state’s scrutiny of insurer billing practices and their impact on healthcare providers. 

The administration determined that Cigna’s policy, which automatically reduces higher-level E/M codes based on internal criteria without formal dispute, violates state insurance law and has caused payment delays for providers. Maryland’s order requires insurers to formally dispute claims and request supporting documentation from providers rather than unilaterally lowering reimbursement. 

E/M codes are used to reflect the complexity of patient visits, including clinical decision-making and the time required for care. While Cigna maintains that its policy aligns with American Medical Association guidelines and affects only about 1% of in-network physicians, critics argue the practical impact is broader. 

For providers in Maryland, the ruling restores a clear process to contest claim reductions and signals potential regulatory oversight in other states. Although the case involves medical E/M codes, the decision is also relevant to dentists as it highlights that automated adjustments to claims without proper documentation or dispute processes could be subject to regulatory scrutiny.  

The case underscores ongoing tension between insurers seeking to manage costs and providers advocating for fair, transparent reimbursement, emphasizing that automated processes cannot override state law.