Health Giant Cigna Improperly Rejects Thousands of Patient Claims, Lawsuit Alleges

According to a federal lawsuit, health insurance firm Cigna rejected hundreds of thousands of patient claims automatically using a computer algorithm rather than individually reviewing each one as required by California law.

The class action lawsuit claims that Cigna Corp. and Cigna Health and Life Insurance Co. turned down more than 300,000 payment requests in just two months of last year, according to The Associated Press. It was filed on Monday in federal court in Sacramento.

The Lawsuit Against Cigna

(Photo : by Zhong Zhi/Getty Images for CNBC International)
NANSHA, CHINA - NOVEMBER 19: Dr.Chun Yuan Chiang, Founder of IHDpay Group, Co-chair Digital-Health-Golobal-Initiative of UNSDG, Jai Verma, CEO & Board Member of Cigna DIFC and Global Head of Government Solutions of Cigna International and Dai Ying, CIO of GE Healthcare China speak with Nancy Hungerford, anchor of CNBC on Day 2 of CNBC East Tech West at LN Garden Hotel Nansha Guangzhou on November 19, 2019 in Nansha, Guangzhou, China.

According to the lawsuit, the business spent an average of just 1.2 seconds each review to determine whether claims satisfied certain conditions using an algorithm known as PXDX, short for "procedure-to-diagnosis."

The lawsuit claimed that numerous claims were subsequently forwarded to doctors who approved the denials.

The lawsuit argues that Cigna ultimately engaged in a "illegal scheme to systematically, wrongfully and automatically" deny member claims in order to avoid having to pay for critical medical procedures.

More than 2 million of Cigna's 18 million American customers live in California.

Two Cigna members in the counties of Placer and San Diego who were compelled to pay for tests after Cigna rejected their claims filed the case on their behalf.

According to the lawsuit, Cigna failed to investigate medical bill submissions in accordance with California's mandate that such investigations be "thorough, fair, and objective". A jury trial and unspecified damages are requested. Only a small percentage of policyholders appeal denied claims, therefore Cigna "uses the PXDX system because it knows it will not be held accountable for wrongful denials," according to the lawsuit.

The complaint, according to a statement from Cigna Healthcare, "appears highly questionable and seems to be based entirely on a poorly reported article that skewed the facts."

The approach, according to the business, is designed to expedite payments to physicians for frequent, reasonably priced operations through a review mechanism that is in line with industry standards and has been utilized for years by other insurers.

How Healthcare Algorithms are Changing the Industry?

Algorithms are becoming increasingly common in healthcare. These mathematical formulas are used to automate tasks, make predictions, and improve decision-making.

In addition to diagnosis and treatment, algorithms are also being used to improve the efficiency of healthcare delivery.

For example, algorithms can be used to automate the scheduling of appointments, to manage patient records, and to track the effectiveness of treatments. This can free up doctors and nurses to focus on providing care to patients.

While algorithms offer many potential benefits, there are also some concerns about their use in healthcare. One concern is that algorithms may be biased, meaning that they may not accurately reflect the needs of all patients.

Another concern is that algorithms may be used to make decisions that are not in the best interests of patients.