ProPublica’s investigation reveals that Cigna, one of the largest insurers in the U.S., has implemented a system allowing its doctors to instantly reject insurance claims on medical grounds without reviewing the patient’s file. This has resulted in unexpected bills for many patients.
Over two months in the previous year, Cigna doctors denied over 300,000 payment requests using this method, averaging 1.2 seconds per case. The company’s system, known as PXDX, uses an algorithm to flag mismatches between diagnoses and what the company deems acceptable tests and procedures. Medical directors then sign off on these denials in batches, without seeing any patient records. This practice has raised concerns about its legality and fairness to patients.
Thought-Provoking Questions & Insights:
- Ethical Implications: How does the practice of instantly rejecting claims without a thorough review impact the trust between patients and insurance providers?
- Legal Concerns: Given that many state insurance laws require company doctors to review claims before rejecting them, how does Cigna’s PXDX system align with these regulations?
- Patient Advocacy: Considering that only a small percentage of patients might appeal a denial, what measures can be put in place to ensure patients are adequately informed and supported in challenging unfair denials?