NANOSNET

As SVP for NANOS Advocacy we will periodically send messages via NANOSNET to inform you of important issues and potential avenues for advocacy. This message pertains to US members. 

There are major changes underway in insurance reimbursement policies that may affect your practice. Beginning October 1, 2025, multiple insurers-including Cigna and Aetna (and BCBS starting November 1, 2025)-are implementing automatic downcoding for Evaluation and Management (E/M) office visit codes. This means that claims for high-level E/M codes (levels 4 and 5) may be automatically reduced to lower-paying levels if payer algorithms judge the diagnosis or documentation insufficiently complex, sometimes without detailed review of your medical records.

https://www.cmadocs.org/newsroom/news/view/ArticleId/50972/CMA-calls-on-physicians-to-speak-out-against-Cigna-s-unlawful-downcoding-policy?utm_source=perplexity

This practice risks significant loss of revenue for work legitimately completed and may create barriers for your patients' access to complex specialty care. It also increases administrative effort, as appeals must be filed to correct downcoded claims.

You can take several steps to protect your practice and help oppose these policies:

1. Carefully monitor your billing and Explanation of Benefits (EOBs) for signs of unjustified downcoding and, when appropriate, challenge the downcoding. You can directly reach out to insurers via their credentialing, claims, or provider relations teams to request claim reconsideration and policy review. 

2. Ensure thorough documentation of the medical complexity and time spent for each patient, as supported by current CMS and specialty guidelines.

3. Alert the Advocacy Committee for North American Neuro-Ophthalmology Society (NANOS) if you begin to observe this occurring, so we can advocate broadly against these practices as a collective voice.

4. Take action by contacting your congressional representatives, describing how automatic downcoding erodes access to complex specialty care and weakens fair reimbursement for work legitimately performed.

What is NANOS doing? 

We are writing to the insurers Cigna, Aetna and BCBS to explain the complexity of our specialty and the concern we have in automatic downcoding for legitimate use of the codes.  The AAO did advocate to have ophthalmology excluded from automatic downloading from the insurer, Humana recently.  However neuro-ophthalmology may still suffer automatic downcoding if we do not stay vigilant. 

The AAN has also sent a letter to CMS requesting addressing the matter: https://www.aan.com/siteassets/home-page/policy-and-guidelines/advocacy/comment-letters/2025/25-final-physician-orgs-sign-on-em-downcoding.pdf

Your advocacy is crucial to preventing future automatic downcoding and preserving appropriate payment for complex neuro-ophthalmology care. For further assistance, notify our organization or use contact points provided by the AAO or AAN.

Thank you for your commitment to quality patient care and your ongoing vigilance on this important issue.