Federal Lawsuit: There’s a lawsuit in Sacramento, California, against Cigna, a big health insurance company. They’re being accused of using a computer program to say “no” to lots of patient claims without really looking at them. This might be breaking the state’s rules that each claim should be checked individually.
The lawsuit says that Cigna said no to more than 300,000 payment requests in only two months. They used a thing called the PXDX algorithm, which supposedly only took 1.2 seconds to look at each request.
Following this automated process, batches of claims were forwarded to doctors, who reportedly signed off on the denials. The lawsuit claims that Cigna’s doctors allegedly denied claims without checking patient files. This could result in many patients not having insurance and having to pay unexpected medical bills.
The lawsuit says that Cigna planned a “bad scheme” to always say no to claims so they don’t have to pay for important medical procedures. With 18 million U.S. members, including over 2 million in California, Cigna’s actions are being closely scrutinized in the legal battle.
The lawsuit is about two people who have Cigna insurance in Placer and San Diego counties. They want money and a trial with a group of people called a jury because they think Cigna didn’t do a good job looking into their medical bills like California says they should. Some people say that Cigna used the PXDX system because they thought they wouldn’t get in trouble for denying claims since only a few people actually challenge the denials.
Cigna Healthcare doesn’t believe the lawsuit is true. They say the claims are based on a badly written article that doesn’t tell the truth.
Cigna says that the PXDX system helps doctors get paid faster for simple and not-too-expensive procedures. They follow the same rules as other insurance companies that have been around for a long time. The company emphasizes that the review occurs after patients have received treatment and does not result in denials of care. If you mess up the codes, Cigna says they’ll help you figure out how to fix it and how to appeal if you need to.