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