Aetna and Cigna’s Upcoming Policy Shifts: A Warning for RCM Leaders

Across the conversations we have with RCM leaders of different specialties and organization sizes, one theme remains consistent: keeping up with payers is a pain. Revenue cycle teams often tell us that it’s nearly impossible to stay ahead of payers, and the only thing that they can hope for is to try to stay in lockstep. In the latest edition of this saga: Aetna and Cigna’s upcoming policy shifts. 

Aetna recently announced a new inpatient payment policy that would apply to all Medicare facilities that participate in Aetna’s MA plans, and it triggered intense backlash from leading industry groups. The policy impacts emergent or urgent inpatient stays greater than one midnight by creating a new “level of severity inpatient payment policy”, stating effective November 15, Aetna will pay urgent inpatient stays at a lower, observation-level rate, requiring hospitals to appeal to receive the full contracted inpatient payment.

This practice is not only administratively burdensome but potentially unlawful, sidestepping long-standing billing norms like the two-midnight rule and undermining clinical judgment. 

Cigna is set to enact a similar policy on October 1, allowing the insurer to unilaterally downcode high-level E/M claims if Cigna deems the submitted diagnosis does not support the complexity of the visit. This will force providers to file a post-payment appeal to receive the deserved payment amount.

Unfortunately, these are not one-offs. They’re a symptom of a broader long-standing trend: commercial payers deploying aggressive tactics under the radar to reduce payment responsibility—without warning, transparency, or standardization.

The Bigger Picture: A New Era of “Silent Policy Shifts”

These changes reinforce an escalating pattern: frequent, quietly enforced changes in coverage rules, authorization requirements, and reimbursement logic. These changes often aren’t published in centralized databases. Instead, they’re buried in obscure PDFs, emailed provider bulletins, or payer portal updates.

And by the time an RCM team spots these reimbursement shifts, the financial damage is already done.

Key challenges for providers:

• No standard format for payer policy updates
  
• No alerts or lead time to adapt workflows
  
• No clear audit trail on why claims are underpaid
  
• High administrative burden to reverse negative payer decisions
  
  

What to Do About Aetna and Cigna’s New Policies 

If your organization relies heavily on inpatient volume—or if you’ve already started seeing unexplained downcoding or denials from Aetna—you are not alone.

Start with:

• A payer-specific denial trend audit
  
• A review of recent Aetna downgrades and payer communications
  
• A conversation with your RCM team about revenue cycle automation

Adonis is already supporting clients who faced similar shifts from other payers earlier this year and helping them recover hundreds of thousands in lost revenue through predictive intelligence and automated remediation.

How Adonis Levels the Playing Field

At Adonis, we believe providers should never be caught off guard by a payer policy change again.

Our Adonis platform was built to address exactly this issue—real-time monitoring for policy changes, autonomous actions, and full claim resolution. We quickly detect shifting payer behavior before it escalates to massive denied claims and revenue leakage.

Real-Time RCM Monitoring and Alerting

Our system doesn’t wait for issues to pile up. Adonis flags underpayments and spikes in denials—like those driven by changes in payer policies—as they emerge, so teams can respond before revenue is lost. Adonis then interprets the financial patterns and recommends precise actions, like escalation triggers for medical necessity denials or batch appeals for inpatient downgrades.

Agentic Automation

To accelerate speed to cash and improve team capacity, Adonis AI Agents step in—automating status checks, enabling medical record/chart submission, generating appeals, and even following up on submission to ensure appeal success. Your team stays focused on strategy while we handle the high-friction tasks.

Complete Claim Resolution

Connect people, process, and technology with seamless integration to eliminate fractured RCM workflows. We deliver claims to full resolution and payment, multiplying your output, not your headcount.

RCM Isn’t Fair. Adonis Makes It Work for You.

The reality is that payer policy complexity is a deliberate feature, not a bug. Payers are reshaping how, when, and if providers get paid—often through policies that offer little transparency or recourse.

Adonis helps revenue cycle teams:

• Catch policy changes early, not after significant revenue hit
  
• Hold payers accountable with timely documentation and evidence
  
• Scale automation, not just headcount, to increase team efficiency
  
• Protect margins by working more claims and capturing the revenue you deserve
  

Final Thought: You Can’t Out-Manual the Payers Anymore

Payer tactics are evolving. It’s become nearly impossible for teams operating in the status quo to keep up. You need real-time insight, intelligent automation, and a partner that’s always looking ahead.

Explore how Adonis helps RCM teams stay ahead of payer policy changes: Request a Demo