Cigna's headquarters in Bloomfield, Connecticut. Credit: JHVEPhoto
Physicians have slowed an effort by Cigna to hold down spending on some types of claims in California.
Cigna wants to use the strategy to manage what it says are inaccurate, unreasonably high bills from a small percentage of providers for patient "evaluation and management" services, or efforts to assess patients' health and oversee their care.
Cigna has agreed to postpone implementation of the "E/M services" code editing strategy for fully insured health plans in California, according to a report the California Medical Association posted Monday.
The change affects employers with fully insured health maintenance organization plans and preferred provider organization plans.
The company is continuing to offer the strategy to employers with self-insured health plans, the association said.
Shortly after the original version of this article was published, Cigna emphasized in a statement that the move is likely to be temporary.
“Our new policy that ensures the limited number of impacted physicians are reimbursed appropriately for E/M services took effect as planned, with the exception of certain California HMO and PPO plans," the company said. "We anticipate the policy will also take effect for these plans' claims in California after the state regulators complete their review of the additional information we provided."
What it means: Physicians are mounting a formidable effort to resist efforts by health insurers and health plan administrators to control what the payers classify as questionable strategies for making claims bigger.
The backdrop: Health care providers and health plans use a complicated system of codes, or numbers, to communicate about patients' health problems and the procedures used to address the problems.
Health plans are now using advanced statistical analysis techniques and artificial intelligence technology to detect what they believe to be provider efforts to use inaccurate claim codes to push up claims in unfair ways.
Providers are using AI tools of their own to document care more thoroughly and fight health plans' claim denials.
Aetna, for example, has been clashing with providers in California and elsewhere over efforts to edit claims for many high-cost procedure bundles.
UnitedHealth's UnitedHealthcare arm recently announced a new approach to "editing," or cutting, what it will pay for some lab test claims.
Cigna and California: The California Department of Managed Health Care and the California Department of Insurance oversee Cigna's health insurance and managed care plan operations in California.
Federal regulators at the U.S. Labor Department's Employee Benefits Security Administration oversee Cigna's teams that administer claims for self-insured employer plans
The California Medical Association and other provider groups have persuaded California's health insurance and managed care regulators to review Cigna's new evaluation and management services claim-editing rules.
Cigna stopped trying to apply the rules to commercial HMO plans in California Oct. 1, and it agreed to pause implementation for fully insured PPO plans in the state for 30 days starting Nov. 9, according to the California Medical Association.
Jodi Black, an association executive, said in the association's report that Cigna's effort to apply claim editing rules automatically would hurt physicians who deliver complex care.
Cigna maintains that the new approach may help increase the accuracy of medical bills and reduce the impact of overbilling on medical costs.
"The policy does not lead to more claim denials or delay care for customers," the company said. "It protects them from improper bills."
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