Following the implementation of downcoding policies by two major private payers, Aetna and Cigna, effective Oct. 1, 2025, AASM analyzed payer trends and identified additional health plans with active or proposed downcoding programs targeting higher-level evaluation and management (E/M) services. These include Ambetter (Centene), Anthem (Elevance Health), BCBS of North Carolina, BCBS of Massachusetts, BCBS of Tennessee, Humana, Kaiser Permanente, Molina Healthcare, UnitedHealthcare, WellCare, and Sunshine Health.

While these programs vary by state and line of business, many also rely on claims analytics rather than clinical review, allowing E/M codes to be automatically adjusted before payment. Automatic downcoding has broad implications, including administrative burden, delayed access to care, reduced reimbursement, and erosion of clinical value.

AASM’s action plan:

  1. AASM has sent letters to Ambetter, Anthem (Elevance), BCBS of North Carolina, BCBS of Massachusetts, BCBS of Tennessee, Humana, Kaiser Permanente, Molina Healthcare, United Healthcare, Wellcare, and Sunshine Health.
  2. Members are encouraged to download and personalize the payer template letter to send directly to affected insurance companies, emphasizing how these policies disrupt patient care and misrepresent clinical complexity. A list of the payer contacts can be accessed here.
  3. AASM staff will continue to actively work to schedule meetings with payer representatives to advocate for fair and transparent review processes.

Members are encouraged to contact coding@aasm.org with any questions regarding downcoding policies.