Cigna Sued Over Algorithm Allegedly Used To Deny Coverage To Hundreds Of Thousands Of Patients
Jul 24, 2023
03:01 pm EDT
Cigna, the healthcare and insurance giant, was hit with a lawsuit on Monday that alleges the company systematically rejects claims in a matter of seconds, thanks to an algorithmic system put in place to help automate the process—further raising questions about how technology could harm patients as more healthcare organizations look to embrace AI and other new tools.
The suit, which was filed in California and is seeking class action status, was brought forth by a pair of plaintiffs who were denied coverage by Cigna. One plaintiff, Suzanne Kisting-Leung, was referred for an ultrasound because of a suspected risk of ovarian cancer. Another, Ayesha Smiley, had been tested for a vitamin D deficiency at the order of her doctor.
The health insurer’s digital claims system, called PXDX, is an “improper scheme designed to systematically, wrongfully, and automatically deny its insureds medical payments owed to them under Cigna’s insurance policies,” the complaint alleges.
Excerpt:
The suit follows a Propublica investigation in March that detailed Cigna’s software system for approving and denying claims in batches. The algorithm works by flagging discrepancies between a diagnosis and what Cigna considers “acceptable tests and procedures for those ailments,” according to the lawsuit.
https://www.forbes.com/sites/richardnieva/2023/07/24/cigna-sued-over-algorithm-allegedly-used-to-deny-coverage-to-hundreds-of-thousands-of-patients/?sh=26f54f414b14
( Come on, tell me how shocked you are. )
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This is becoming a real burden to the Doctors because everything becomes an appeal that requires more input from the Doctors. I suspect that they are spending more time with follow-up justifying the treatments than they actually spend with the patients. that is assuming that you can get them to do it.
I think this is driving a move towards concierge care in the area I live. I have heard of numerous doctors that have given up insurance and just taking on a reduced patient load that pay cash.
On top of it being profitable to deny as much as possible, Cigna has software to do just that so they don't even have to pay a human to do it. A twofer!!
The profit motive is perfectly fine when it comes to widgets, ball peen hammers or hotel rooms. If I don't like their money grubbing cheapness, I just don't buy it again or return to that hotel. And they get a bad review. For healthcare coverage? That paradigm breaks down in heart wrenching fashion.
