Fact Check: Cigna saved millions by rejecting claims without doctor reviews!

Fact Check: "Cigna saved millions by rejecting claims without doctor reviews!"

What We Know

Recent investigations have revealed that Cigna, one of the largest health insurance providers in the United States, employs a review process known as the procedure-to-diagnosis (PXDX) review system. This system allows claims to be denied without a thorough review by medical professionals. According to a report by ProPublica, Cigna's doctors can reject claims in a matter of seconds, often without reviewing the patient's medical files. Internal documents indicate that during a two-month period, Cigna doctors denied over 300,000 claims using this method, averaging only 1.2 seconds spent on each case. The report suggests that this automated system leads to improper denials of coverage for medically necessary procedures, forcing patients to pay out-of-pocket for services that should be covered under their insurance policies (E&C Republicans).

The House Energy and Commerce Committee has expressed concern over these practices, noting that Cigna's PXDX process may violate regulations requiring insurers to conduct thorough reviews of claims (E&C Republicans). Furthermore, a class-action lawsuit has been filed against Cigna, alleging that the company’s practices violate California state law, which mandates that insurers must conduct a comprehensive review before denying claims (CBS News).

Analysis

The evidence presented in the reports from ProPublica and the House Energy and Commerce Committee raises significant concerns about Cigna's claims denial practices. The PXDX review process appears to prioritize efficiency and cost savings over patient care, as it allows for rapid denials based on algorithmic assessments rather than individual clinical judgment. This is corroborated by statements from former Cigna doctors who described the process as merely clicking to approve denials without engaging with the patient files (ProPublica).

Critics, including former insurance executives and regulatory officials, have questioned the legality and ethical implications of such a system. They argue that spending mere seconds on a claim does not comply with the requirement for a "thorough, fair and objective investigation" as mandated by various state laws (ProPublica). Cigna has defended its practices, claiming that the system is designed to expedite the approval of routine claims, but this assertion is met with skepticism given the high volume of denials reported (ProPublica).

The reliability of the sources is strong, particularly given that ProPublica is a well-respected investigative journalism organization known for its in-depth reporting on issues of public interest. The House Energy and Commerce Committee's involvement adds a layer of governmental scrutiny that further emphasizes the seriousness of the allegations against Cigna.

Conclusion

The claim that "Cigna saved millions by rejecting claims without doctor reviews" is True. The evidence indicates that Cigna's PXDX review process allows for widespread denial of claims without adequate medical review, leading to significant financial savings for the company at the expense of patient care. This practice raises ethical and legal concerns, as it appears to violate regulations designed to protect patients from arbitrary insurance denials.