Maryland's Insurance Administration fined Cigna $80,000 and ordered the insurer to stop automatically downcoding evaluation and management (E/M) claims without formally disputing them with providers, according to an April 17 article published by WCH Service Bureau.
The administration determined that Cigna's policy -- which reduces higher-level E/M codes based on internal criteria -- violates state insurance law by bypassing the required process of requesting supporting documentation from providers before lowering reimbursements. E/M codes reflect the complexity of patient visits, including clinical decision-making and time spent on care. Cigna has maintained that its policy aligns with American Medical Association guidelines and affects roughly 1% of in-network physicians.
Maryland's order requires insurers to formally dispute claims and request documentation from providers rather than unilaterally reducing reimbursement. While the ruling involves medical E/M codes, it carries implications for dental providers, as it signals that automated claim adjustments made without proper documentation or dispute processes may be subject to regulatory scrutiny. The case also highlights the potential for similar enforcement actions in other states.
