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‘A system built to deny claims’: Insurer denials frustrate patients and providers

Cigna has mastered a system to deny claims in bulk. But the insurer’s latest blunder isn’t unique to the insurance industry.

1.2 seconds.

That’s how long it takes for ‘an expert’ at Cigna to look at your medical claim and determine the fate of your care.

A whopping 1.2 seconds.

They do it through the help of an algorithm known as ‘PXDX.’ This is the corporate shorthand at Cigna for a list known as ‘procedure-to-diagnosis.’

It’s causing patients lots of frustration, but it’s saving Cigna lots of money.

It’s a system that aligns diagnostic tests with the procedures they are approved for, and it’s supposed to make Cigna even more efficient at denying claims that the insurer considers unnecessary.

But doctors and patient advocates are alleging the system is unfair to patients – shocker.

Allegedly, the system allows the health insurance company to turn down claims that it once paid, and the company’s doctors never have to open a file — they can deny claims in bulk — simply with an electronic signature.

In fact, Dr. Alan Muney, who helped develop the PXDX system, said “that it would be an ‘administrative hassle’ to require company doctors to manually review each claim rejection.”

In other words, Cigna doesn’t want to fork the cash to take the time to individually review patient claims. This is frustrating for the 18 million patients with Cigna plans, whose life and death hangs on the balance of their insurer covering their needed medical care.

ProPublica reports that in a two-month period last year, Cigna’s doctors denied over 300,000 requests for payments using the PXDX algorithm.

But what does it matter, when Cigna’s saving so much money?

But Cigna’s not alone. Muney built a similar system at UnitedHealthcare that lets the insurer’s doctors deny claims in bulk. This is the problem with insurers who have no true context for a patient’s medical issues and are blindly denying claims based on an algorithm.

The instances at Cigna and UnitedHealthcare speak to a broader pattern within the insurance industry: Health insurers continue to find faster, cheaper ways to deny claims and boost their bottom lines.

It seems pointless, then —patients go through all the trouble of visiting a doctor to find answers to their health problems and collaborate with their care team on an appropriate care plan — when it’ll all be denied by an insurance company in 1.2 seconds.

So, next time you get a notice in the mail that your coverage was denied due to ‘medical necessity,’ you might want to question whether a human or computer made that decision.

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