MSSNY is contacting physicians statewide to assess the impact of insurance companies’ automatic downcoding, a growing concern that undermines fair reimbursement and burdens physician practices. As of October 1, Cigna and Aetna are automatically downcoding claims.

Automatic downcoding occurs when insurers unilaterally reduce the level of a billed Evaluation and Management (E/M) service or procedure code without reviewing the physician’s supporting documentation. Instead, claims are automatically flagged and adjusted by internal algorithms based on coding guidelines or statistical norms. The outcome is reduced reimbursement, even when the billed service level was appropriate and supported by the medical record.

This practice has serious implications. For physicians, it means lost revenue, time-consuming appeals, and increased administrative workload. For patients, it threatens the sustainability of physician practices, particularly in underserved areas where margins are already thin. Automatic downcoding also raises broader concerns about fairness and transparency in claims adjudication, as it bypasses medical judgment and disregards the physician’s expertise.

By sharing your experiences, you will help MSSNY document the scope of this issue and determine whether further advocacy, regulatory engagement, or legal action is warranted. Submit your experiences here.