What Is the New Insurance Billing Policy?
The insurance billing policy represents a significant shift in how insurers review and reimburse medical claims. Beginning October 1, 2025, Cigna announced it would implement a new reimbursement review process for office visits billed at the highest complexity levels—specifically Level 4 and Level 5 visits.
Understanding Billing Levels
Medical billing codes categorize patient visits based on complexity and time required. Level 4 and Level 5 visits represent the most complex cases, commanding higher reimbursement rates. These codes are typically used for patients with multiple health conditions, complicated diagnoses, or situations requiring extensive medical decision-making.
How Cigna’s Billing Policy Works
Cigna’s approach to the insurance billing policy involves a review-first, appeal-later process that has generated significant controversy among healthcare providers.
The Downcode-First Approach
Under this policy, Cigna will automatically review claims for Level 4 and Level 5 office visits. If the insurer determines the visit doesn’t meet the appropriate complexity threshold, it will reduce the reimbursement rate without first consulting the physician. Providers who disagree with this reduction must then submit medical records to substantiate the higher billing code, after which Cigna will adjust reimbursement accordingly.
Justine Sessions, a spokesperson for Cigna, stated: “This change is designed to reduce overbilling, promote accurate documentation, and align with the American Medical Association coding guidelines. Importantly, this policy change does not lead to more denials or delay care for customers in any way.”
Aetna’s Similar Approach
Cigna isn’t alone in implementing this type of insurance billing policy. Aetna enacted a similar policy in Connecticut in March 2025, according to company spokesperson Phillip Blando.
Alignment with National Standards
Blando emphasized that Aetna’s billing criteria “are based on CMS and American Medical Association guidelines,” adding that “evaluating the appropriateness of levels 4 and 5 codes helps us ensure providers are billing for their services consistent with national guidelines.”
Why Physicians Are Concerned
Healthcare providers have expressed significant concerns about the insurance billing policy, with many fearing it will create substantial administrative challenges.
Administrative Burden
Peter Hahn, a cardiologist practicing in Uncasville, Connecticut, articulated the frustration many physicians feel: “My understanding, and the understanding of everyone who’s been rallying the cry about this is, the new policy just says they’re going to downcode everybody and it’s up to us to go back and fight and prove we’re not doing it inappropriately. Only then, after we file the appeal, can we get paid for the services rendered.”
Hahn estimates he already dedicates approximately “a full day a week” to “fighting with insurance companies,” and worries this policy will only exacerbate that burden.
Congressional Intervention
The concern from providers escalated to the federal level when U.S. Senator Richard Blumenthal wrote directly to Cigna, calling for the policy’s reversal. In his September 11 letter, Blumenthal stated: “If allowed, this new policy will significantly increase administrative burdens and costs for physicians while jeopardizing patient care. I urge you to reverse this decision and instead work closely with physicians to address any billing concerns.”
Scope and Clarification of the Policy
Following widespread concern and confusion, Cigna issued an important clarification on September 9 that narrowed the scope of its insurance billing policy.
Limited Target Group
Cigna clarified that the policy will only impact approximately 1% of doctors in its network—specifically those whose “records indicate as having a consistent pattern of coding at a higher [level] for routine visits compared to their peers.” This includes providers who, for example, bill diagnoses such as “earache” or “sore throat” as Level 4 or 5 visits.
Communication Gaps
The initial announcement lacked crucial details about the policy’s scope, including how many providers would be impacted and what percentage of visits would be downcoded. This information gap created panic and confusion, particularly among small, independent providers.
Cigna has since sent notifications to all providers who will be affected by the new policy, according to Sessions, though the company declined to specify how many Connecticut doctors would be impacted.
Expert Opinions on the Policy
Medical professionals have offered varied perspectives on the insurance billing policy, with many emphasizing concerns about methodology and fairness.
The Wrong Information Problem
David Eagle, a New York-based oncologist, acknowledged that insurers have the right to audit physician billing practices but argued there’s a fundamental flaw in Cigna’s approach. “Cigna is making reimbursement decisions based on claims filed, which don’t contain all the information necessary to appropriately assess the complexity of a visit,” Eagle explained. “You’re just using the wrong information set. And then it’s the problem of the physician to fight back, claim by claim, visit by visit, to get paid appropriately.”
Specialty-Specific Comparisons
Mark Camel, a retired neurosurgeon and co-founder of Greenwich-based Orthopaedic and Neurosurgery Specialists, stressed the importance of comparing providers within their specialties. An oncologist treating complex cancer patients shouldn’t be compared to an orthopedic surgeon seeing patients with knee pain, as their patient complexity levels differ significantly.
Camel stated the policy is “okay as long as each physician is compared within their specialty because of the variation of types of visits.”
Impact on Healthcare Providers
The insurance billing policy creates multiple challenges for healthcare providers, particularly smaller practices with limited administrative resources.
Financial Implications
When claims are automatically downcoded, providers experience immediate revenue reduction. The appeals process requires additional staff time and resources, creating a financial double-bind for medical practices already operating on thin margins.
Patient Care Delays
Eagle highlighted how insurance policies requiring extensive documentation and appeals can delay patient care. “Everybody has to scramble on the medical side after the fact to explain and justify treatment for cancer patients, so it causes delays in treatments. And so much extra work,” he explained.
What This Means for Patients
While the insurance billing policy primarily affects physicians and healthcare systems, patients may experience indirect consequences.
Institutional Response
The Connecticut Hospital Association called for policy reversal, with spokesperson Nicole Rall stating: “We have concerns that these new policies will create uncertainty for providers and patients and add significant administrative burden and cost. They should be rescinded. Clear, transparent policies are essential to supporting fair reimbursement and ensuring patients’ continued access to care.”
Access to Care Concerns
When physicians spend more time fighting billing disputes, they have less time for patient care. Additionally, some providers may become more reluctant to accept certain insurance plans if administrative burdens become too excessive, potentially limiting patient access to care.
Conclusion: The new insurance billing policy implemented by Cigna and Aetna represents a significant change in how insurers approach medical billing oversight. While companies claim these policies prevent overbilling and align with national guidelines, physicians argue they create unnecessary administrative burden, use incomplete information for decision-making, and may ultimately harm patient care. As this policy continues to roll out, the healthcare community will be watching closely to see whether the limited scope clarified by Cigna addresses provider concerns or whether additional modifications will be necessary.
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