LUGPA Policy Update: Insurer Downcoding Policies Threaten Independent Urology Practices and Patient Access to Care

September 2025 

LUGPA continues to monitor payer policies that threaten the stability of independent urology practices. Recent actions by major insurers, most notably Cigna and Aetna, target high-level Evaluation and Management (E/M) codes (levels 4 and 5) with automatic downcoding that bypasses medical record review. These policies increase administrative burdens, cut reimbursements, and jeopardize patient access to timely, high-quality care.

What Is Downcoding?

Downcoding occurs when insurers unilaterally reduce a billed E/M code (e.g., 99214 or 99215) to a lower level, often through algorithms or third-party reviews, without verifying documentation. Unlike standard claim denials, this process skips due process and shifts the burden to practices to appeal.

Current Insurer Policies

• Cigna (Policy R49): Effective October 1, 2025, Cigna will reduce new and established patient visits (99204–99205, 99214–99215) without medical record review. On September 8, LUGPA sent a letter to Cigna’s CEO urging suspension, citing risks to coding integrity and undue burdens.
• Aetna Claim and Code Review Program: Expanded in June 2025, this program uses vendor reviews to downcode levels 4 and 5 E/M services across multiple care settings. The process lacks transparency and has drawn objections from physician groups.

These actions reflect a growing trend flagged by the AMA, which warns that automatic downcoding adds red tape and cuts payments without clinical justification.

Why It Matters for Independent Urology

Independent urology practices operate with lean resources and are disproportionately harmed by downcoding.

• Administrative Strain: Appeals require intensive documentation, diverting time and staff from patient care.
• Risk of Consolidation: Reduced reimbursements push independent groups toward hospital acquisition, where care is costlier: commercial payers often pay hospitals more than 1,300% higher rates than independent practices.

Impact on Physicians and Patients

• For Urologists: Complex cases often justify higher-level codes. Downcoding pressures physicians to undercode, discourages thorough evaluation, and fuels burnout.
• For Patients: Community-based practices deliver accessible, lower-cost specialty care. If reimbursement cuts lead to closures or consolidation, patients will face longer waits, higher bills, and fewer options for advanced care.

LUGPA’s Advocacy

LUGPA is actively pressing payers to reverse these policies:

• Calling on Cigna to suspend Policy R49.
• Urging Aetna to improve transparency and due process.
• Supporting targeted audits for true outliers, not blanket downcoding.

We encourage members to:

• Monitor claims closely for downcoding indicators (e.g., CO150).
• Appeal promptly with robust documentation.

LUGPA will continue to lead on this issue to protect independent practices, preserve fair reimbursement, and ensure patients retain access to high-quality urologic care.