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CIGNA Uses AI to Deny Claims
Why Dr. Lane doesn’t Take Insurance Anymore
A new lawsuit alleges that Cigna uses artificial intelligence (AI) algorithms to inappropriately deny “hundreds or thousands” of claims at a time, bypassing legal requirements to complete individual claim reviews and forcing providers to bill patients in full.
In a complaint filed last week in California’s eastern district court, plaintiffs and Cigna health plan members Suzanne Kisting-Leung and Ayesha Smiley and their attorneys say that Cigna violates state insurance regulations by failing to conduct a “thorough, fair, and objective” review of their and other members’ claims.
The lawsuit says that instead, Cigna relies on an algorithm, PxDx, to review and frequently deny medically necessary claims. According to court records, the system allows Cigna’s doctors to “instantly reject claims on medical grounds without ever opening patient files.” With use of the system, the average claims processing time is 1.2 seconds.
Cigna says it uses technology to verify coding on standard, low-cost procedures and to expedite physician reimbursement. In a statement to CBS News, the company called the lawsuit “highly questionable.”
Do you want a picture of what it is like to be a provider and send in a claim? Let’s play a game on a different topic:
Who are you? Do you have proof of your identity?
Sure, you say! Here is my driver’s license (while showing it to me).
A month goes by and I send you another request, “do you have any other proof of your identity?”. You send me something else (a passport, for example)
A month goes by.
I write to you again, “do you have any other proof?”
Do you see where this is going? Every month the insurer send me a request for more information about a single patient visit ‘to confirm that a legitimate claim was made for us to pay’ (just like me asking you to prove your identity). There is no limit to the number of times they can ask me with no intention of ever paying me.
The insurer (like me asking you to prove your identity) is never satisfied with what is presented because they are not interested in proving anything; they just do not intend to pay, ever. Months go by while I continue to send them the requested additional documentation.
After a while I am supposed to turn the claim over to the patient and inform them that they have to pay for the dates of service because their insurer won’t pay me (denied the claim because of my failure to show ‘medical necessity’)
When the patient doesn’t pay I should turn it over to a collections agency to get my money.
What the system needs is an objective (outside) agency who decides whether a proper request was made for payment for treatment rendered; whether the proper proof was offered. If the legitimacy is made, the insurer should pay the provider. The present system is asking an insurer to pay money that they want to keep (from premiums) to a provider which, in turn, means the insurer has less money.
The more money an insurer keeps the more ‘profit’ they have which they may give back to the employees in the form of bonuses, but mostly they give out to the people at the top of the insurance company with very little trickling down to the line employees routinely denying the claims.
If legal heat is put on the insurers to pay more money to the providers (by denying fewer claims) they just fire a few people on the bottom of the company and not the people on top making it clear to the employees that denying claims is good for the company.
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