Cigna headquarters in Bloomfield, USA. Credit: askarim/Shutterstock.com
Managed health care and insurance provider Cigna is being sued again. This time a class action lawsuit was filed claiming that the company used automated intelligence to deny medical care claims – sometimes within seconds of the claim being made.
The lawsuit, which was filed in U.S. District Court in Connecticut Aug. 25, alleges the plaintiff was denied reimbursement for a medically necessary colonoscopy as a result of Cigna "automatically and algorithmically denying claims." This latest lawsuit makes similar claims to one filed against Cigna in federal court in California in July.
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This type of medical claim occurs when a patient sees a doctor and submits the billing to their insurer. If there was no pre-approval on the billing, it is the insurer's job to determine whether to pay for the procedure or deny payment. But the July lawsuit, filed in federal court in eastern California, on behalf of plaintiffs Ayesha Smiley and Suzanne Kisting-Leung, argues Cigna's claim reviews were not "thorough," "fair," nor "objective" because the company supposedly made claim determinations by computer without conducting any investigation.
The complaint states that Cigna used an automated system referred to as "procedure-to-diagnosis" or PxDx that "employs an algorithm to identify discrepancies between diagnoses and what the Cigna defendants consider acceptable tests and procedures for those ailments and automatically deny claims on those bases."
Clarkson Law Firm, which filed the case, said in a news release that, "Cigna's algorithmic review process trades patient care for profit, allowing the provider to eliminate the cost of necessary review by doctors and qualified professionals and instead rely on impersonal, illegal review by an almost completely automated algorithm."
Related: Denials of health insurance claims are rising: Are algorithms to blame?
In a statement reported in other news outlets Cigna retorted, saying: "Based on our initial research, we cannot confirm that these individuals were impacted by PxDx at all. To be clear, Cigna uses technology to verify that the codes on some of the most common, low-cost procedures are submitted correctly based on our publicly available coverage policies, and this is done to help expedite physician reimbursement. The review takes place after patients have received treatment, so it does not result in any denials of care."
Both the House Energy and Commerce committees, and state regulators, have begun investigations into Cigna's usage of the software. In July, two Cigna members in California filed a lawsuit alleging that they were unfairly denied payment due to the insurer's reliance on PxDx.
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