Cigna Claims Denial Process - New Profit Center
April 1, 2023
Current State - Deny Deny Deny
We have previously discussed how insurance companies operate in their own self interest, not yours. Here is a story about how Cigna health insurance auto denies claims - whether your doctor says you need the test/procedure or not.
Advocates, Here is a republishing of a ProPublica Investigation into the Cigna health insurance behemoth. ProPublica found that in a two month period they denied 300,000 claims spending about 1.2 seconds reviewing each. The denials are actually computer generated and save the company a fortune. in claims.
The article is titled “How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them” by Patrick Rucker, Maya Miller and David Armstrong
Here is a link to the article.
Cigna developed a computer operated flowchart system, PXDX, to automatically pay for some procedures and tests and deny others that were not listed in the flow chart. Doctors sign off on the denials.
Recently, one physician, a patient and Cigna policy holder, was ordered to have a vitamin D deficiency blood test. Since this had never shown up before in his medical record, it was denied. He continued to ask Cigna in the appeals process how it would ever be diagnosed if there were no blood test (that is the standard accepted medical practice to detect this deficiency). Eventually, he took the appeal for the $350 test to a board outside of Cigna. This took significant time and effort on his part. Most people don’t have the time or energy to pursue such denials, they just pay it. I know I’ve done that several times and many others I’ve met have as well. We just gave up and the insurance company wins.
Some doctors working for Cigna are able oversee the generation of 60,000 denials a month. If you looked at them all it would be about 1.2 seconds each.
Cigna’s response to all of this is that they are not denying medical care, they are just denying payment.
This is as non-transparent as it gets.
One of the fallacious arguments made against Universal Healthcare is that the approval process is opaque and you won’t be able to have your test or procedure covered. I’ve read Rep. Jayapal’s bill for the 117th Congress and it called out medically necessary treatments are covered. Period. Her new bill comes out in May. Let’s over communicate to our representatives that this is what we want.
Have a good weekend.
TAKE ACTION
Resistbot
Text SIGN PFSHKQ to 50409 to tell your representative and senators and the president that it is high time we had universal healthcare like the rest of the industrialized world.
I am writing to you because I am tired of insurance companies and other for-profit entities standing between me and my healthcare provider. ProPublica just published (March 25th, 2023) an article describing how Cigna is auto-denying claims, as many as 300,000 in a 2 month period. Most of us give up and just pay the bill, which is Cigna hopes for. Here is a link to the article https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims.
Representative Jayapal will be reintroducing her Single Payer Universal Healthcare bill in mid May. It will cover medically needed treatments for all of us cradle to grave, prescriptions, hospitals, doctors at far lower costs than we pay now.
This is a basic part of our country’s infrastructure and I want you to sign on to it and make it a reality for all of us.
Resources
Organizations to Contact
Physicians for a National Health Plan
Save Democracy
Chop Wood, Carry Water by Jessica Cravens
Resources
Contact White House or other federal agencies: usa.gov/federal-agencies
Contact the White House https://www.whitehouse.gov/contact/
Contact State and Federal Representatives
https://www.commoncause.org/find-your-representative/change-your-address
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By Resistbot: Resist.bot
Hi Gary, Those are excellent questions that I will research and and answer. I am sure that many states have different rules. I recall once having an anesthesia claim denied. I asked to appeal that decision. They put someone else on the phone who said, "Let's see here, NO, claim denied". I was a t work and the time there had more value than arguing on personal time. You see how it goes.,,,Alan
PS - I think comments are visible to any who get to substack. FYI
Alan, thank you for this. It's reimbursement driven by a profit motive. As you point out, many people don't have the time or ability to appeal such denials. So the onus is on the patient, often the person least able to devote attention to insurance runarounds.
Yes, let's advocate for universal healthcare. Politics is also the art of the possible. Are there any laws in place to penalize insurers for such (mal)practices? How should we advocate so that insurers act in good faith -- a lofty goal? Do insurers build in other barriers, such as forced arbitration that prevents class-action suits?