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BeckyDem

(8,361 posts)
Tue Jul 25, 2023, 07:39 AM Jul 2023

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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Cigna Sued Over Algorithm Allegedly Used To Deny Coverage To Hundreds Of Thousands Of Patients (Original Post) BeckyDem Jul 2023 OP
Not....surprised that is. But so damn frustrating. Biophilic Jul 2023 #1
But at least we don't have the Government between us and our doctors. genxlib Jul 2023 #2
That's interesting, and it makes sense we would see some go BeckyDem Jul 2023 #3
Same as court referees deciding whether you're allowed to sue bucolic_frolic Jul 2023 #4
Yes, it is scary. BeckyDem Jul 2023 #5
Oh. The one all for-profit insurance companies use. Mmmmkay. n/t CousinIT Jul 2023 #6
I have worked there for a handful of months. I have learned so so so much. LizBeth Jul 2023 #7
Cigna: Give us $$ to play in the casino that is Wall St Attilatheblond Jul 2023 #8
Yes, does anyone remember when HMO's came out decades ago and the Republicans were hollering flying_wahini Jul 2023 #10
Yep, I'm old enough to remember all that GOP fuss Attilatheblond Jul 2023 #17
We have long appointment waits too. paleotn Jul 2023 #14
Yep. Months to get appointments Attilatheblond Jul 2023 #18
Kick dalton99a Jul 2023 #9
Sued??? Old Crank Jul 2023 #11
F**k that drmeow Jul 2023 #15
+1 n/t area51 Jul 2023 #20
Oopsie... Those silly computers. Chakaconcarne Jul 2023 #12
The profit motive in healthcare. What could possibly go wrong? paleotn Jul 2023 #13
Giving the computers the power to deny gives the executives cover for scamming policy holders Attilatheblond Jul 2023 #19
Every claim denied means more money in the pockets of the owners. Midnight Writer Jul 2023 #16

genxlib

(5,570 posts)
2. But at least we don't have the Government between us and our doctors.
Tue Jul 25, 2023, 07:55 AM
Jul 2023


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.

Attilatheblond

(2,849 posts)
8. Cigna: Give us $$ to play in the casino that is Wall St
Tue Jul 25, 2023, 09:54 AM
Jul 2023

and we will have our shiny computer system laugh at your valid claims.

Defenders of the current system of medical care delivery in the US point to Britain and Canada's 'long wait for appointments' as a way to scare Americans off the idea of national health care systems. Wonder how many of those 1%er enablers have tried to get medical appointments lately. The wait is long here too.

flying_wahini

(7,053 posts)
10. Yes, does anyone remember when HMO's came out decades ago and the Republicans were hollering
Tue Jul 25, 2023, 10:17 AM
Jul 2023

About getting between a patient and their doctor. How non medical people were screwing it up
For Big insurance. How they were just secretaries making medical decisions?
(So they can laugh at your valid claims) welcome to DU AttilatheBlond!

Attilatheblond

(2,849 posts)
17. Yep, I'm old enough to remember all that GOP fuss
Tue Jul 25, 2023, 06:06 PM
Jul 2023

And even went toe to toe with some Cigna bean counters who tried to practice medicine. LOL.

And thank you, Flying_wahini (love your handle!) for the welcome. Been an off & on lurker for ages and decided to sign up recently after seeing elon let the dogs loose at Twitter. This is a much saner place than what is happening over at brand X

paleotn

(18,412 posts)
14. We have long appointment waits too.
Tue Jul 25, 2023, 10:46 AM
Jul 2023

Try getting in to see a dermo guy or an endodontist. In some parts of the country, just getting scheduled for routine exams takes weeks to months. Triage is alive and well in US medicine, unless you've got the bucks to move you to the front of the line.

Attilatheblond

(2,849 posts)
18. Yep. Months to get appointments
Tue Jul 25, 2023, 06:10 PM
Jul 2023

Heard wife of a billionaire 'gentleman rancher' (no cattle, no agriculture production at all, just leases pasture) complain that if we went to a national health care system everybody would be able to see a doctor and she wouldn't be able to get same day appointments like she is able to do under the current system.

paleotn

(18,412 posts)
13. The profit motive in healthcare. What could possibly go wrong?
Tue Jul 25, 2023, 10:43 AM
Jul 2023


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.

Attilatheblond

(2,849 posts)
19. Giving the computers the power to deny gives the executives cover for scamming policy holders
Tue Jul 25, 2023, 06:14 PM
Jul 2023

Sure, there is always a licensed MD signing off on the 'decision' but those clowns are not really doctors, just cogs in a machine to sentence people to needless suffering, even death, for a paycheck.

Midnight Writer

(22,271 posts)
16. Every claim denied means more money in the pockets of the owners.
Tue Jul 25, 2023, 02:07 PM
Jul 2023

One hell of a way to run our healthcare, where denying care is key to higher profits.

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