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Cigna, the healthcare and insurance giant, was hit with a lawsuit on Monday that alleges the company systematically rejects claims in a matter of seconds, thanks to an algorithmic system put in place to help automate the process—further raising questions about how technology could harm patients as more healthcare organizations look to embrace AI and other new tools.
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See our earlier article from 27 March - How CIGNA Saves Millions
The suit, which was filed in California and is seeking class action status, was brought forth by a pair of plaintiffs who were denied coverage by Cigna. One plaintiff, Suzanne Kisting-Leung, was referred for an ultrasound because of a suspected risk of ovarian cancer. Another, Ayesha Smiley, had been tested for a vitamin D deficiency at the order of her doctor.
The health insurer’s digital claims system, called PXDX, is an “improper scheme designed to systematically, wrongfully, and automatically deny its insureds medical payments owed to them under Cigna’s insurance policies,” the complaint alleges.
After the lawsuit was filed Monday, Cigna defended the software system. “PXDX is a simple tool to accelerate physician payments that has been grossly mischaracterized in the press,” spokesperson Justine Sessions said in a statement. “The facts speak for themselves, and we will continue to set the record straight.”
The suit follows a Propublica investigation in March that detailed Cigna’s software system for approving and denying claims in batches. The algorithm works by flagging discrepancies between a diagnosis and what Cigna considers “acceptable tests and procedures for those ailments,” according to the lawsuit.
Over two months last year, the company denied more than 300,000 claims, spending an average of 1.2 seconds on each claim, Propublica reported. While medical doctors signed off on the denials, the system didn’t require them to open patient medical records for the review. The complaint says that this violates a California competition law for unfair and fraudulent business acts. The suit also alleges the system violates the state’s insurance code for failing to adopt a “reasonable standard” for processing claims.
The complaint comes as a boom in artificial intelligence and other advanced technology has raised questions about the future of work, potentially upending every industry from advertising to insurance. Healthcare is one sector where a high-tech makeover could both be beneficial—aiding doctors in filling out burdensome paperwork or helping narrow down diagnoses—but also fraught, due to issues of patient privacy, access to care and the high cost of medical bills.
Cigna isn’t alone in adopting new tech to remake its processes. In April, Google’s cloud division unveiled new tools for healthcare claims processing that uses AI to organize data and streamline decision-making. Blue Shield of California and Bupa are among the companies using the tool.
The firm representing the plaintiffs, Malibu, California-based Clarkson Law, has previously taken on tech giants when it comes to AI. Earlier this month, the firm filed lawsuits against OpenAI, the company behind ChatGPT, and Google, which has its own generative chatbot called Bard, for allegedly stealing the data of millions of people—including artists and writers who copyrighted their works—to train and build their AI products.
The suit, which was filed in California and is seeking class action status, was brought forth by a pair of plaintiffs who were denied coverage by Cigna. One plaintiff, Suzanne Kisting-Leung, was referred for an ultrasound because of a suspected risk of ovarian cancer. Another, Ayesha Smiley, had been tested for a vitamin D deficiency at the order of her doctor.
The health insurer’s digital claims system, called PXDX, is an “improper scheme designed to systematically, wrongfully, and automatically deny its insureds medical payments owed to them under Cigna’s insurance policies,” the complaint alleges.
After the lawsuit was filed Monday, Cigna defended the software system. “PXDX is a simple tool to accelerate physician payments that has been grossly mischaracterized in the press,” spokesperson Justine Sessions said in a statement. “The facts speak for themselves, and we will continue to set the record straight.”
The suit follows a Propublica investigation in March that detailed Cigna’s software system for approving and denying claims in batches. The algorithm works by flagging discrepancies between a diagnosis and what Cigna considers “acceptable tests and procedures for those ailments,” according to the lawsuit.
Over two months last year, the company denied more than 300,000 claims, spending an average of 1.2 seconds on each claim, Propublica reported. While medical doctors signed off on the denials, the system didn’t require them to open patient medical records for the review. The complaint says that this violates a California competition law for unfair and fraudulent business acts. The suit also alleges the system violates the state’s insurance code for failing to adopt a “reasonable standard” for processing claims.
The complaint comes as a boom in artificial intelligence and other advanced technology has raised questions about the future of work, potentially upending every industry from advertising to insurance. Healthcare is one sector where a high-tech makeover could both be beneficial—aiding doctors in filling out burdensome paperwork or helping narrow down diagnoses—but also fraught, due to issues of patient privacy, access to care and the high cost of medical bills.
Cigna isn’t alone in adopting new tech to remake its processes. In April, Google’s cloud division unveiled new tools for healthcare claims processing that uses AI to organize data and streamline decision-making. Blue Shield of California and Bupa are among the companies using the tool.
The firm representing the plaintiffs, Malibu, California-based Clarkson Law, has previously taken on tech giants when it comes to AI. Earlier this month, the firm filed lawsuits against OpenAI, the company behind ChatGPT, and Google, which has its own generative chatbot called Bard, for allegedly stealing the data of millions of people—including artists and writers who copyrighted their works—to train and build their AI products.
It is not only the online claims system but the nonresponsive attitudes of Cigna with which they treat the plan members. My case for a BPH procedure was referred to Cigna by my doctor at the Dubai American Hospital around May 2021 for approval. Neither me nor my hospital heard back from Cigna for months despite repeated reminders through emails and telephones calls. And finally when they responded they rejected my request notifying me that the procedure recommended is a new one that is not yet proven to be effective even though this procedure is FDA-approved
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