ProPublica has published its investigation into Cigna’s system for denying payment for claims as not medically necessary without review by a medical director in order to save itself millions of dollars. The report highlights the experience of one patient for whom Cigna denied payment for a blood test as not medically necessary – even though the blood test confirmed his physician’s diagnosis of a condition, which, if left untreated could lead to osteoporosis and bone fractures.

ProPublica reported that Cigna’s system “allows its doctors to instantly reject a claim on medical claims without opening the patient file, leaving people with unexpected bills.”  According to the report, Cigna’s PXDX system contains algorithms that identify “mismatches” between medical tests and procedures and diagnoses for which Cigna considers those tests or procedures appropriate. Cigna medical directors then sign the denials in batches without reviewing medical records or using their medical judgment to determine whether a particular patient may need a particular test or procedure. As one former medical director quoted in the article stated:  “We literally click and submit. It takes all of ten seconds to do 50 at a time.” Cigna tracks how many claims medical directors deny each month. Company records reviewed by ProPublica showed that Cigna medical directors denied over 300,000 requests for payment over a two-month period, spending an average of 1.2 seconds on each claim.

As explained in the report, the PXDX system saves Cigna money in two ways. First, it saves money by excusing it from paying the claims. Second, because the medical necessity review process itself is costly, Cigna saves money by not having to pay the review costs. Other insurers also engage in similar practices. For example, Cigna’s PXDX system was designed by its former Chief Medical Officer, Alan Muney, MD, who is reported as saying that he created a similar system at UnitedHealthcare, which allowed its medical directors to quickly deny claims in bulk.

In response to the investigation, Cigna stated that the report was “biased and incomplete.” It also emphasized that the system did not deny patients medical tests or treatment.  Rather, it only denies payment for the tests or treatment. According to the report, tests and procedures on the PXDX list are generally low-cost procedures, which most patients will pay themselves rather than to go through the time and hassle of an appeal. Cigna reports that only 5% of patients appeal denied claims.

The patient whose claim for a blood test was denied by Cigna, Nick van Terheyden, is a physician himself. He appealed the denial through Cigna’s external review process and won, with the independent physician reviewing the claim finding that the test was both medically necessary and appropriate.  As Dr. van Terheyden stated about Cigna’s process:  “It’s not good medicine. It’s not caring for patients.”

The ProPublica report is linked here.

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