[texas booster]

The rejection of van Terheyden’s claim was typical for Cigna, one of the country’s 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 Terheyden’s 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.”

[texas booster]

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 Cigna’s review system. Patients expect insurers to treat them fairly and meaningfully review each claim, said Dave Jones, California’s former insurance commissioner. Under California regulations, insurers must consider patient claims using a “thorough, fair and objective investigation.” “It’s 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.) Former Cigna doctors confirmed that the review system was used to quickly reject claims. An internal corporate spreadsheet, viewed by the news organizations, lists names of Cigna’s medical directors and the number of cases each handled in a column headlined “PxDx.” The former doctors said the figures represent total denials. Cigna did not respond to detailed questions about the numbers. Cigna's explanation that its review system was designed to approve claims didn’t make sense to one former company executive. “They were paying all these claims before. Then they weren’t,” said Ron Howrigon, who now runs a company that helps private doctors in disputes with insurance companies. “You’re talking about a system built to deny claims.”

[Leaning Right]

For those approaching Medicare, you’ve got two choices for gap coverage. You can stick with original Medicare, and buy a supplement.

Or you can ditch Medicare, and buy an “advantage” plan run by an insurance company. Advantage plans are usually cheaper, and often much cheaper.

This Cigna story illustrates why I stuck with original Medicare.
Of course, your mileage may vary.

[Secret Agent Man]

Health insurance as we know it - like this - should just go away.

Its done the same thing to medicine as govt student loans did to higher education.

[Bonemaker]

Claim denial specialist is a job description with some of these insurance companies. No medical knowledge required. They have the process down to a fine art. Am in process of appealing dental claim for a bridge. Plan benefits list bridges as a covered procedure. Denial letter from company says we don’t cover bridges. F ‘em. Scheisters. I’ve had much better luck with pet insurance.

[kvanbrunt2]

Well if you want a funds transfer system instead of insurance this is what you get. Imagine having oil changes covered by your car insurance. Insurance should be for Major medical stuff and emergencies. There is no cost containment in routine care if you go to a funds transfer system.

[kvanbrunt2]

Plus if anyone actually thinks someone reviews insurance claims they are nuts. Some get reviewed if they cannot be automatically adjudicated by a computer system. The number of claims processed in a funds transfer system are hugh and serial. /s

[kvanbrunt2]

And then if you follow the money. What entities are building huge facilities. Hospitals.

[cyclotic]

Years ago I took my daughter to the ER because she was coughing uncontrollably. This had gone on for several hours. ER couldn’t diagnose it so they admitted her. She spent a day or two in the hospital. It did turn out to be relatively minor.

the 8th grade dropout sitting at a desk at CIGNA denied the claim declaring that it wasn’t an emergency.

The probably didn’t like that I called their guy an 8th grade dropout either. When we appealed, CIGNA called to tell me they scheduled a “hearing” with about eight of their people and me. I said “sure, I’ll schedule a conference room at my office for you to come over.”

They told me it would be at their office at which point I reminded them that it was their problem and that I wasn’t lifting a finger in my defense.

They followed up with a call to my wife threatening to garnish my wages. At that point, I went to my company HR and told them to stuff it because they can’t garnish what doesn’t exist. “I quit.”

Long story short, they didn’t let me quit and the company dealt with CIGNA from then on. Somehow they worked it out.

When I changed jobs, not having CIGNA was a criteria.

[mund1011]

“We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.”

+++++++++

Looks like the same caliber people / systems doing the signature verification for the Arizona elections that shafted Kari Lake.

[Vermont Lt]

My wife’s hospital system stopped accepting CIGNA because dealing with them was difficult and their payments were so bad it was costing them money.

I wonder how many national health systems need to dump them before they learn?

[STJPII]

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