On March 13, 2026, the Maryland Insurance Administration (MIA) fined Cigna $80,000 and ordered the insurer to stop automatically downcoding evaluation and management (E/M) claims. The policy at the center of the order, Cigna’s Reimbursement Policy R49, had been in effect since October 1, 2025. For roughly 5 months, the policy automatically reduced higher-level E/M codes (99204-99205, 99214-99215, and 99244-99245) when Cigna’s internal algorithm decided the visit “did not adhere to certain complexity standards.”
The 2024 KFF analysis of CMS transparency data found insurers denied 19% of in-network claims in 2024 and 37% of out-of-network claims for a combined average of 20% of all claims.
Three weeks after the Cigna fine, on April 7, 2026, the MIA issued Bulletin 26-9 extending the same prohibition to every health insurer operating in Maryland.1
One state, one payer, one policy to rule them all. The mechanism behind it is everywhere, and oncology practices feel it harder than most.
Here are 3 things every oncology practice leader should know about downcoding:
- It is happening more often, at greater scale, and at higher speed than ever before
- It is largely preventable when you have access to the right data
- In oncology, where E/M complexity is genuinely high, the per-encounter dollar impact is significant, and the documentation defense can be more nuanced than in most other specialties
What Is Downcoding?
Downcoding is what happens when you bill for a service and are paid for a lower level than you billed. A new oncology consult documented and submitted as 99205 comes back paid at 99204. An established patient visit billed as 99215 is paid as 99214. The submitted code is not changed on the claim, and the payer does not issue a formal denial. The downcode shows up as a remark code on the explanation of benefits, and the lower payment is what hits your bank account.2
That last detail is the one most practices miss. Downcoding does not show up in your denials report. If you are only chasing Claim Adjustment Reason Codes denials, you are not seeing this revenue leak at all.
Why It Is Hitting Harder Now
Automatic algorithmic downcoding is not new, but the scale and the speed have changed. Cigna’s R49 was one of several 2025 policy launches. Aetna implemented a parallel program effective October 1, 2025. Humana expanded predictive analytics–based downcoding into commercial and Medicare Advantage plans the same year.
The pattern reflects a broader trend.
The American Medical Association’s 2025 Prior Authorization Physician Survey, released in May 2026, found that three-quarters of physicians (74%) report that denials have increased over the past 5 years, and 6 in 10 express concern that AI may further increase denial rates.3 The 2024 KFF analysis of Centers for Medicare & Medicaid Services transparency data found insurers denied 19% of in-network claims in 2024 and 37% of out-of-network claims for a combined average of 20% of all claims.4
For oncology specifically, the stakes are not theoretical. Reviewing pathology, adjusting chemotherapy regimens, managing immunotherapy risk, coordinating with radiation oncology, and stacking comorbidity management into a single encounter routinely meets the standard for high-complexity medical decision-making (MDM).
The clinical work is real.
The question is whether your documentation makes the complexity visible to an algorithm that has never seen a chemotherapy decision tree.
Step 1: Find the Downcodes
You cannot solve for something you don’t know is happening. The first step is identifying where downcodes are happening, by which payers, and at what dollar impact.
If your practice management system has a built-in mismatch report, run it. If it does not, build a custom report that compares 2 data points already sitting in your system:
- CPT billed (available on the 837-claim file)
- CPT reimbursed (available on the 835-remittance file)
Run it across a meaningful time period. For most oncology practices, a rolling 12 months gives you enough volume to see patterns without diluting current policy impact. If your practice management (PM) vendor cannot produce this report, that is a vendor conversation worth scheduling this week.
Once you have the data, assess by payer, frequency, and revenue impact. This is where the strategic decisions get made. A payer that downcodes 15 of your claims for $80,000 in lost revenue is a larger problem than a payer that downcodes 85 claims for $63,000.
Your work plan should also reflect the dollars, not just the volume.
Pay particular attention to the codes that show up most often in oncology E/M billing: 99204, 99205, 99214, 99215, and the consult codes 99244 and 99245. These are precisely the codes targeted by the recent wave of automatic downcoding policies.
Step 2: Solve for It
Identification is half the work. The other half is building the workflows that catch downcodes quickly, recover the revenue, and prevent recurrence.
Flag downcoded claims as soon as they post. Work with your PM vendor to build a rule that compares billed CPT to reimbursed CPT and flags any mismatch on E/M codes. Where that is available, use it. Where it is not, your billing team needs a daily or weekly task to work the flagged list. Do not let it become a “we’ll get to it” list. The Cigna R49 case made one thing very clear: when payers reduce reimbursement without a formal denial, the burden falls on the practice to appeal. The appeal has to actually happen.
Flag downcoded claims as soon as they post. Work with your PM vendor to build a rule that compares billed CPT to reimbursed CPT and flags any mismatch on E/M codes. Where that is available, use it.
Evaluate provider compensation agreements that are based on Work Relative Value Units. This is the question most groups have never asked. If your oncology productivity report reflects that a provider billed a 99215 and you were reimbursed at a 99214, how is that addressed in the compensation calculation? If there is no policy for that scenario, add a task to the strategic plan to evaluate, create, and implement one. Without it, downcoding can quietly compress provider compensation without anyone noticing.
Strengthen the documentation in payer-recognizable language. Oncology MDM is inherently complex, but algorithms only see what is on the note. The AMA’s payer downcoding resource is direct on this point: the visit notes need to explicitly capture the number and complexity of problems addressed, the data reviewed, and the risk of morbidity.2 For a new patient consult, that means PET scan review and biopsy results named specifically, the chemotherapy regimen options considered, the risk discussion documented, and the coordination with surgical or radiation oncology captured in the note. Strong documentation is your primary defense against an algorithm comparing your coding patterns to those of your peers.
What the Maryland Precedent Teaches
The MIA’s order against Cigna is the first significant regulatory pushback against automatic E/M downcoding, but it will not be the last. California’s Department of Managed Health Care has paused similar policies pending review. Indiana passed legislation in 2026 restricting payer downcoding practices. The Medical Group Management Association Government Affairs Council and state medical societies are tracking the issue actively.
For oncology practices, 2 concrete actions follow from the Maryland precedent:
- If you have Cigna E/M claims in Maryland with dates of service from October 1, 2025 onward, audit them. The MIA order requires Cigna to reprocess affected claims. Practices that identify the downcodes and submit them for reprocessing recover the revenue. Practices that do not, do not.
- Document the pattern even where the regulatory pushback has not yet happened. State medical societies and the AMA are building the evidence base for the next regulatory action. Your data contribute to that case.
The Principle
Downcoding is not a billing problem. It is a strategy problem disguised as a billing problem, and the data you need to solve for it are already sitting in your PM system. The work is finding it, assessing it by payer and revenue impact, building the workflows that catch it at adjudication, and documenting your oncology MDM in language that an algorithm can read.
The revenue cycle is never “done.” Downcoding will continue to evolve as payers refine their algorithms and regulators respond to provider pushback. What stays constant is the discipline: pull the data, work the plan, and don’t let revenue walk out the door under a remark code that never made it into your denials report.
References
- Maryland Insurance Administration. Consent Order MIA-2026-03-009 (In the Matter of Cigna Health and Life Insurance Company). March 13, 2026; Bulletin 26-9, April 7, 2026. Order available via Maryland State Medical Society (MedChi): www.medchi.org/Portals/18/MIA-2026-03-009%20Letter%20&%20Order.pdf
- American Medical Association. Payer evaluation and management (E/M) downcoding programs: what you need to know. 2022. www.ama-assn.org/system/files/payer-em-downcoding-resource.pdf
- American Medical Association. AMA survey: Prior authorization reform pledge falls short with physicians. May 13, 2026. www.ama-assn.org/press-center/ama-press-releases/ama-survey-prior-authorization-reform-pledge-falls-short-physicians
- KFF. Claims Denials and Appeals in ACA Marketplace Plans in 2024. March 24, 2026. www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/
