Cigna (and likely United Healthcare) has a system to deny
by IAND75 (2023-03-25 09:58:44)

payment on claims without actual physician review. It is what a lot of people have suspected for a long time. A computer algorithm flags claims for denials and medical directors sign off as having reviewed them. They do it in bulk, without ever opening the patient’s file.

Of course it is a cost savings for Cigna, but an enormous expense for physicians, hospitals, and patients. But they aren’t the customer.

Linked article is from ProPublica. The following is from the article:

Howrigon, the former Cigna executive, said that although he was not involved in developing PXDX, he can understand the economics behind it.

“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 PXDX list is focused on tests and treatments that typically cost a few hundred dollars each, said former Cigna employees.

“Insurers are very good at knowing when they can deny a claim and patients will grumble but still write a check,” Howrigon said.

Muney and other former Cigna executives emphasized that the PXDX system does leave room for the patient and their doctor to appeal a medical director’s decision to deny a claim.

But Cigna does not expect many appeals. In one corporate document, Cigna estimated that only 5% of people would appeal a denial resulting from a PXDX review.