How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them — Patrick Rucker / ProPublica / Sharif Alam

Yesterday while surfing news items on internet, the below news caught my attention. Took time to go through the entire article. It’s alarming!

We are having off and on problems with Cigna’s outfit in Kualalumpur, Malaysia with respect to settlement of invoices, primarily due to managerial/staff incompetence as well as cavalier attitude in the claim department. But what is happening at a much higher level of Cigna is incomprehensible.

This is an agency that UN has contracted as a custodian of active staff/retirees healthcare/welfare. If what the article unearthed is true, UN definitely has a case to defend!

Wonder if high ups in UN responsible for contract management is aware of these revelations!!! If not, shouldn’t we bring it to their attention??

Hope you find a way to bring to their attention!! It’s time Cigna is held to account for their alleged unethical practices!

Sharif Alam

How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them

This article is part of ProPublica's 'Uncovered' Series

How the Insurance Industry Denies Coverage to Patients

Please click here to read the full article on ProPublica 

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

Here is a short summary:

Cigna has been accused of denying up to 300,000 claims per month by a system that allows its doctors to reject claims without reviewing patients' medical histories. The system, which bypasses regulations stating that doctors must review patient records before denying claims, involves a computer using algorithms to identify any discrepancies between diagnoses and procedures, and doctors then signing off on the denials in batches. 

The accusations were made in internal Cigna documents obtained by investigative journalism group ProPublica and the Capitol Forum.

"Internal documents and former company executives reveal how Cigna doctors reject patients’ claims without opening their files. “We literally click and submit,” one former company doctor said."

"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."

"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.)"

"Cigna emphasized that its system does not prevent a patient from receiving care — it only decides when the insurer won’t pay. “Reviews occur after the service has been provided to the patient and does not result in any denials of care,” the statement said.

"Our company is committed to improving health outcomes, driving value for our clients and customers, and supporting our team of highly-skilled Medical Directors,” the company said."