Cigna Healthcare is pushing back on reporting from ProPublica and a lawsuit in California that accuse the payer of denying large batches of members' claims without individual review, thereby denying them coverage for certain services.
In March, ProPublica reported that Cigna may be violating state laws by allowing its medical directors to deny large batches of claims without reviewing members' files through an automated claims review process called PxDx. The report said Cigna physicians denied more than 300,000 claims over two months in 2022 through the system, which equated to 1.2 seconds of review per claim on average.
Following the report, state insurance commissioners and federal lawmakers raised concerns and requested more information from Cigna about its claims review process, with some calling for an investigation.
On July 24, two Cigna members filed a class-action complaint in California, alleging the company denied coverage for services using the PxDx tool described in ProPublica's report.
On July 27, Cigna published additional information on its website about its claims review process in an effort to clarify how the company reviews and processes members' claims.
"A recent media story riddled with factual errors and gross mischaracterizations may lead to a misunderstanding and distorted view of a simple process used by Cigna Healthcare and other health insurers to expedite payments to physicians and other providers," the company wrote.
Four key takeaways:
1. The PxDx tool is used to speed up provider reimbursements for about 50 common, low-cost services, including dermabrasion, chemical peels or vitamin D screenings. If a claim is submitted with the correct code, it is paid automatically. If not, the claim heads to a physician for individual review, with no more than 50 claims being sent at a time. Incorrectly coded claims can be resubmitted, reviewed with the physician or appealed.
2. The review process is not prior authorization, so patients receive treatment before a claim is potentially denied. Claims that are denied through the process represent less than 1 percent of Cigna's total claims volume, with 94 percent being approved. If a claim is denied through PxDx, most members do not experience additional costs, especially if they used an in-network provider.
3. The technology behind PxDx is more than a decade old and does not involve algorithms, artificial intelligence or machine learning. The technology is also an industry standard, with similar tools being used by other commercial payers and CMS.
4. Savings generated through the review process benefit members and customers, and Cigna's physicians have no incentive to deny claims.