Cigna Well being Large Accused of Improperly Rejecting Hundreds of Affected person Claims Utilizing an Algorithm

SACRAMENTO, Calif. (AP) — A federal lawsuit alleges that medical health insurance big Cigna used a pc algorithm to robotically reject a whole bunch of hundreds of affected person claims with out inspecting them individually as required by California legislation.

The category-action lawsuit, filed Monday in federal courtroom in Sacramento, says Cigna Corp. and Cigna Well being and Life Insurance coverage Co. rejected greater than 300,000 cost claims in simply two months final 12 months.

The corporate used an algorithm referred to as PXDX, shorthand for ”procedure-to-diagnosis,” to determine whether or not claims met sure necessities, spending a mean of simply 1.2 seconds on every evaluation, in keeping with the lawsuit. Big batches of claims have been then despatched on to docs who signed off on the denials, the lawsuit stated.

“Counting on the PXDX system, Cigna’s docs immediately reject claims on medical grounds with out ever opening affected person information, leaving hundreds of sufferers successfully with out protection and with sudden payments,” in keeping with the lawsuit.

Finally, Cigna performed an “unlawful scheme to systematically, wrongfully and robotically” deny members claims to keep away from paying for medical vital procedures, the lawsuit contends.

Connecticut-based Cigna has 18 million U.S. members, together with greater than 2 million in California.

The lawsuit was filed on behalf of two Cigna members in Placer and San Diego counties who have been pressured to pay for assessments after Cigna denied their claims.

The lawsuit accuses Cigna of violating California’s requirement that it conduct “thorough, truthful, and goal” investigations of payments submitted for medical bills. It seeks unspecified damages and a jury trial.

Cigna “makes use of the PXDX system as a result of it is aware of it won’t be held accountable for wrongful denials” as a result of solely a small fraction of policyholders enchantment denied claims, in keeping with the lawsuit.

In an announcement, Cigna Healthcare stated the lawsuit “seems extremely questionable and appears to be based mostly fully on a poorly reported article that skewed the info.”

The corporate says the method is used to hurry up funds to physicians for frequent, comparatively cheap procedures by way of an industry-standard evaluation course of just like these utilized by different insurers for years.

“Cigna makes use of know-how to confirm that the codes on a few of the commonest, low-cost procedures are submitted appropriately based mostly on our publicly accessible protection insurance policies, and that is accomplished to assist expedite doctor reimbursement,” the assertion stated. “The evaluation takes place after sufferers have obtained therapy, so it doesn’t end in any denials of care. If codes are submitted incorrectly, we offer clear steering on resubmission and tips on how to enchantment.”

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