Cigna physicians deny large batches of claims without reviewing them first, a process that may save the company millions of dollars every year when members don't appeal, ProPublica reported March 25.
According to the report, an internal claims system at Cigna allows medical directors to deny a claim without opening the patient's file. The report claims that 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.
"We literally click and submit," a former Cigna physician told ProPublica. "It takes all of 10 seconds to do 50 at a time."
Many states require medical directors to review patient files and coverage policies before denying claims for medical reasons. ProPublica alleges that Cigna has bypassed these steps by having a computer algorithm complete the review and then having physicians sign off on groups of denied claims.
"It’s hard to imagine that spending only seconds to review medical records complies with the California law," Dave Jones, California's former insurance commissioner, told ProPublica. "At a minimum, I believe it warrants an investigation."
Not all claims go through the specified review system and it is not clear how many are approved or sent to physicians for review, the report said. The review system was instituted more than a decade ago and other payers have used similar processes.
“We categorically disagree with this mischaracterization of our process for accelerating payment of claims for routine, low-cost screenings," a Cigna Healthcare spokesperson told Becker's. "PxDx allows us to automatically pay providers for claims that are submitted with the correct diagnosis codes, and prioritizes our medical directors' time for more complex reviews. It does not create any impediments to or denials of care because it takes place after a patient receives the service, and even a denial does not result in any additional out of pocket costs for patients using in-network providers."