Current Events > How Cigna saves millions by having doctors reject claims without reading them

(+) Yeah! (+)

https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims

When a stubborn pain in Nick van Terheydens bones would not subside, his doctor had a hunch what was wrong.
Without enough vitamin D in the blood, the body will pull that vital nutrient from the bones. Left untreated, a vitamin D deficiency can lead to osteoporosis.

A blood test in the fall of 2021 confirmed the doctors diagnosis, and van Terheyden expected his companys insurance plan, managed by Cigna, to cover the cost of the bloodwork. Instead, Cigna sent van Terheyden a letter explaining that it would not pay for the $350 test because it was not medically necessary.

The letter was signed by one of Cignas medical directors, a doctor employed by the company to review insurance claims.

Something about the denial letter did not sit well with van Terheyden, a 58-year-old Maryland resident. This was a clinical decision being second-guessed by someone with no knowledge of me, said van Terheyden, a physician himself and a specialist who had worked in emergency care in the United Kingdom.

The vague wording made van Terheyden suspect that Dr. Cheryl Dopke, the medical director who signed it, had not taken much care with his case.

Van Terheyden was right to be suspicious. His claim was just one of roughly 60,000 that Dopke denied in a single month last year, according to internal Cigna records reviewed by ProPublica and The Capitol Forum.

The rejection of van Terheydens claim was typical for Cigna, one of the countrys largest insurers. The company has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials. Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show. The company has reported it covers or administers health care plans for 18 million people.

Before health insurers reject claims for medical reasons, company doctors must review them, according to insurance laws and regulations in many states. Medical directors are expected to examine patient records, review coverage policies and use their expertise to decide whether to approve or deny claims, regulators said. This process helps avoid unfair denials.

But the Cigna review system that blocked van Terheydens claim bypasses those steps. Medical directors do not see any patient records or put their medical judgment to use, said former company employees familiar with the system. Instead, a computer does the work. A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity.

We literally click and submit, one former Cigna doctor said. It takes all of 10 seconds to do 50 at a time.
Not all claims are processed through this review system. For those that are, it is unclear how many are approved and how many are funneled to doctors for automatic denial.
Insurance experts questioned Cignas review system.

Patients expect insurers to treat them fairly and meaningfully review each claim, said Dave Jones, Californias former insurance commissioner. Under California regulations, insurers must consider patient claims using a thorough, fair and objective investigation.

Its hard to imagine that spending only seconds to review medical records complies with the California law, said Jones. At a minimum, I believe it warrants an investigation.

Within Cigna, some executives questioned whether rendering such speedy denials satisfied the law, according to one former executive who spoke on condition of anonymity because he still works with insurers.

We thought it might fall into a legal gray zone, said the former Cigna official, who helped conceive the program. We sent the idea to legal, and they sent it back saying it was OK.

Cigna adopted its review system more than a decade ago, but insurance executives say similar systems have existed in various forms throughout the industry.

In a written response, Cigna said the reporting by ProPublica and The Capitol Forum was biased and incomplete.
Cigna said its review system was created to accelerate payment of claims for certain routine screenings, Cigna wrote. This allows us to automatically approve claims when they are submitted with correct diagnosis codes.

When asked if its review process, known as PXDX, lets Cigna doctors reject claims without examining them, the company said that description was incorrect. It repeatedly declined to answer further questions or provide additional details. (ProPublica employees health insurance is provided by Cigna.)

insurance is a fucking scam. i pay hundreds and hundreds and it does literally nothing for me. insurance should pay for small shit too, like a wrist brace and stuff. it's bullshit.

this destroys families

Death penalty

Our lives mean nothing to the almighty dollar

Hope this leads to some lawsuits, but the penalty will probably just be pocket change to them

There is a real easy solution to this

When are we going to demand healthcare reform from our representatives? It sucks always hearing stories like this.

BroodRyu posted...

When are we going to demand healthcare reform from our representatives? It sucks always hearing stories like this.

Never. Human nature demands the suffering of the masses for the sake of the few.

I am so fucking tired of health insurance and Big Pharma getting in the way.

Daily reminder that health insurance exists because there is money to be extracted between a patient and a provider. Insurance wouldn't exist if they couldn't steal from healthcare. Insurance is a fucking scam.

Cigna balls

Just what I needed, lol. I've had a kidney replaced and was on dialysis for three years. Cigna sent me an $8,000 bill, likely for a dialysis session from 2019..when I was fully insured by them from my previous employer(not to mention Medicare). I was wondering why they're trying to bill me for ONE session when I've been getting it 3 days a week for years until my transplant.

When I was hospitalized in December of 2019 (pancreatitis caused by gallstones blocking my bile duct) I was terrified of what it was going to cost me. Every day I was in my room there was more and more money I couldn't afford to pay.

In the end my insurance covered everything except for the amount that got me to my "out of pocket limit" which for a working class person like me was still $5.5k and still an unmanageable amount of debt

I had wished I died instead, but on my second to last day of my stay someone from the financial department of the hospital discussed financial aid possibilities with me.

I ended up only owing $500 which was to be honest still a lot to deal with, but christ it was far better than what I'd get otherwise

Insurance companies are the reason those kinds of things cost so fucking much.

We need state funded medical care several yesterdays ago. It's not a sustainable system as is

I broke my ankle when I had no insurance and got a $63k hospital bill. I told them I'd never be able to pay it and they let me sign up for free state insurance and billed it retroactively so they'd at least get something.

Man, an AI wouldnt reject as many claims.

I got bloodwork and have Cigna. They covered all of it except for the vitamin D test for the same "not medically necessary" reason.
I was severely deficient.

When someone else pays the bills, that same someone else chooses what the bills will be.
Don't pretend it's any better under a State system - that test may have happened six months later, if at all.

Questionmarktarius posted...

When someone else pays the bills, that same someone else chooses what the bills will be.
Don't pretend it's any better under a State system - that test may have happened six month later, if at all.

I hate this talking point against a better healthcare system. Our wait times for most providers and tests is already long.

Its also because of insurance that this stuff is expensive to begin with.

BroodRyu posted...

Its also because of insurance that this stuff is expensive to begin with.

Not going to argue against that.
When you charge a dollar but only get 35 cents, it's going to be $2.86 next time.

Insurance is a joke. I can see my doctor for a routine appointment (which I have every three months) and pay a cash price of $94 if I pay same day. That exact same visit with my insurance is about $250, plus what I'm paying for insurance every month. Even if I deferred and didn't pay same day it would be $150, a full $100 less.

With Good Rx I get my medicine almost as cheap as my insurance price (again, not including what I pay for insurance). I spend $120/month on my medication. Would be maybe $130 without insurance.

Seriously considering dropping it...

Enderknight17 posted...

Good Rx

careful now.
https://www.natlawreview.com/article/examining-ftc-s-goodrx-case-and-growing-risks-improper-data-collection-and

What in the actual fuck.

Antifar posted...

Cigna said its review system was created to accelerate payment of claims for certain routine screenings, Cigna wrote. This allows us to automatically approve claims when they are submitted with correct diagnosis codes.

Oh? What are numbers for how many approvals this algorithm gets? Cause we now know it's fucking denying hundreds of thousands of claims

Questionmarktarius posted...

careful now.
https://www.natlawreview.com/article/examining-ftc-s-goodrx-case-and-growing-risks-improper-data-collection-and

Oh no, they're doing improper data collection just like *checks notes* every company on the planet

Unknown5uspect posted...

Oh? What are numbers for how many approvals this algorithm gets? Cause we now know it's fucking denying hundreds of thousands of claims

59,999 approvals pre month

Most people should take a vitamin D supplement , I do. It actually has a ton of health benefits, particularly in the era of COVID. Vitamin D can help boost your immune system

Really good link op.

DeepFriedSquid posted...

Oh no, they're doing improper data collection just like *checks notes* every company on the planet

HIPAA is whole different type of privacy violation - the "federal prison" type.

Questionmarktarius posted...

When someone else pays the bills, that same someone else chooses what the bills will be.
Don't pretend it's any better under a State system - that test may have happened six months later, if at all.

So if it takes a long time under any system, how are you concluding that a state system with less individual costs won't be better?

Man...I work for the biggest healthcare company and recently got promoted to post pay. Meaning reviewing claims flagged by the "system" to see if we need to do recoupment of money. Some recoupments are legitimate due to billing errors, but some are literally "pulled out the ass" due to guidelines rules they keep changing. Claims that are ok would be recouped if you follow the guidelines, but since we have basic coding knowledge we go over the rules and give them a pass for which we might get errors. Im making more money than ever and at the same time feeling remorse over what I do.

The root of all this is wallstreet and creating shareholder value due to the endless growth thats expected. Healthcare and capitalism should never mix.

thronedfire2 posted...

Hope this leads to some lawsuits, but the penalty will probably just be pocket change to them

Poor guys might only be able to take 3 vacations for each of the next few years.

Some real sad shit

JuanCarlos1 posted...

Man...I work for the biggest healthcare company and recently got promoted to post pay. Meaning reviewing claims flagged by the "system" to see if we need to do recoupment of money. Some recoupments are legitimate due to billing errors, but some are literally "pulled out the ass" due to guidelines rules they keep changing. Claims that are ok would be recouped if you follow the guidelines, but since we have basic coding knowledge we go over the rules and give them a pass for which we might get errors. Im making more money than ever and at the same time feeling remorse over what I do.

The root of all this is wallstreet and creating shareholder value due to the endless growth thats expected. Healthcare and capitalism should never mix.

The root of a LOOOOT of issues we have today.

Name on this meme?

JuanCarlos1 posted...

Healthcare and capitalism should never mix.

Exactly!

The people that design it that way should be imprisoned in tiny cages barely larger than their bodies, water boarded hours daily, and kept alive and in these condition to the fullest ability of medical science for as long as possible.