November 10, 2025
What You Need to Know: CMA has obtained clarification that Cigna’s pause on implementation of the “Evaluation and Management Coding Accuracy” downcoding policy applies to fully insured commercial HMO and PPO products, but not self-insured plans. CMA continues to urge regulators to require full withdrawal of the policy, which the association warns violates state law, conflicts with national coding standards, and increases administrative burdens for physician practices.
The California Medical Association (CMA) has obtained new details about the scope of Cigna’s pause on its “Evaluation and Management Coding Accuracy” reimbursement policy, which would allow the insurer to automatically downcode higher-level Evaluation and Management (E/M) services whenever it determines that documentation does not support the billed level. Physicians disputing these decisions would be required to file an appeal and submit medical records by fax, a process CMA has warned creates unnecessary administrative burdens and costs.
The policy, originally scheduled to take effect October 1, 2025, drew immediate objections from CMA, the American Medical Association, and other physician organizations, which warned that it would create unnecessary administrative costs and delay payment for legitimate claims.
CMA raised legal and compliance concerns with the California Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI). In response, DMHC opened a review, and Cigna agreed to pause the policy for all fully insured commercial HMO products effective October 1, 2025, where it remains paused pending completion of the review. CMA has learned that Cigna will also pause implementation for fully insured PPO products regulated by CDI beginning November 9, 2025, for 30 days while the department conducts its review. The policy remains in effect for self-insured business lines.
CMA continues to caution that this policy appears to violate state law, creates unnecessary administrative burdens, and fails to align with nationally recognized coding standards.
“This policy penalizes physicians for delivering complex care. Instead of supporting appropriate coding and documentation, it creates obstacles that do nothing to improve accuracy or access,” said CMA Vice President for Economic Services Jodi Black. “Downcoding without reviewing the medical record is not ‘coding accuracy’—it’s a payment reduction tool, and it shifts administrative and financial burden onto practices.”
CMA is working closely with both regulatory agencies to ensure that Cigna’s reimbursement practices comply with California law and national coding standards. The association will continue pressing for full withdrawal of the policy and will update members as the DMHC and CDI reviews progress.