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, has been accused of employing a review process known as the Procedure-to-Diagnosis (PXDX) system. This system allegedly allows Cigna to deny claims without a thorough review by medical professionals. According to a report by ProPublica, Cigna's doctors were found to reject claims in batches, spending as little as 1.2 seconds on each case, often without reviewing patient files. This method has reportedly led to millions in savings for the company while leaving patients with unexpected out-of-pocket expenses for necessary medical services (E&C Republicans).

The PXDX system categorizes certain claims as "unnecessary" based on algorithms, effectively bypassing the need for a clinician's judgment. This has raised concerns about the fairness and legality of such practices, as many state regulations require insurers to conduct a thorough review of claims before denial (GMLawyers). Furthermore, it has been noted that only about 5% of policyholders appeal their denied claims, which suggests that many patients may not be aware of their rights or the processes in place to contest these decisions (E&C Republicans).

Analysis

The evidence supporting the claim that Cigna saved millions by rejecting claims without proper doctor reviews is substantial. The investigative report from ProPublica outlines a systematic approach where Cigna's medical directors sign off on denials without reviewing individual cases, a practice that contradicts the expectations set by insurance regulations (ProPublica). Former employees have corroborated this, stating that the review process is heavily automated and lacks the necessary oversight that would typically be expected in medical claims processing (Kantor Law).

Critics of Cigna's practices, including former insurance regulators, have expressed concerns that such a rapid denial process does not comply with legal standards for fair claim reviews. For instance, California's former insurance commissioner highlighted that spending mere seconds on a claim review is unlikely to meet the requirements for a thorough investigation (GMLawyers). Additionally, the fact that a significant percentage of Medicare Advantage coverage denials were overturned upon appeal further indicates that the initial denials may not have been justified, suggesting systemic issues within Cigna's claims processing (E&C Republicans).

Cigna has disputed these claims, labeling the reports as "biased and incomplete" and asserting that their review system is designed to expedite the approval of claims when submitted correctly (ProPublica). However, the overwhelming evidence from various sources indicates that the company's practices have led to substantial financial savings at the expense of patient care.

Conclusion

Verdict: True
The claim that Cigna saved millions by rejecting claims without doctor reviews is supported by credible investigations and testimonies from former employees. The PXDX review process, which allows for rapid denials without proper medical oversight, has been shown to contribute to significant savings for the company while adversely affecting patients who are left to cover unexpected medical costs. The evidence suggests that Cigna's practices may not only be unethical but could also violate regulatory standards for insurance claim reviews.