ProPublica and The Capitol Forum reported this month on a company-designed pattern of inappropriate claim rejections by Cigna Healthcare. According to insurance laws and regulations, before health insurers reject claims for medical reasons, company doctors must review them. 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. Cigna, one of the country’s largest insurers, 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. 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. Cigna adopted its review system more than a decade ago, but insurance executives say similar systems have existed in various forms throughout the industry. “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.” Cigna carefully tracks how many patient claims its medical directors handle each month. Twelve times a year, medical directors receive a scorecard in the form of a spreadsheet that shows just how fast they have cleared cases. One Cigna Medical Director, who was investigated, rejected 121,000 claims in the first two months of 2022. “Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.” Cigna knows that many patients will pay such bills rather than deal with the hassle of appealing a rejection, according to Howrigon and other former employees of the company. The ProPublica report can be reviewed in its entirety at: https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims?s=08
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