Investigative Report Shows Health Care Insurance Company Cigna Pressured Doctor to Deny Claims
By Consumers for Quality Care, on May 22, 2024
A new investigative report from ProPublica is shining light on the dishonest practices employed by Cigna, practices that interfere with the doctor-patient relationship, pressuring doctors to reject insurance claims.
Dr. Debby Day had been employed by Cigna for 15 years when the company gave her an ultimatum in late 2020: either decide patient claims more quickly or run the risk of getting fired.
Day believed she had a responsibility to her patients, not her employer, to see that they were given the adequate care they needed. As a Medical Director for Cigna, she would review notes from nurses that either had denied a patient’s claim or were unsure whether a claim should go through. She would then make the final determination about whether the claim would be covered. Day was concerned about the thoroughness of the nurses’ work, and she wanted time to ensure that in each case, the right decision was being made.
Day said she was falling behind on cases, as compared with her peers, who were clearing cases at a faster rate by simply agreeing with the nurses’ notes and accepting their decision, a practice known inside Cigna as “click and close.”
“Deny, deny, deny. That’s how you hit your numbers,” said Day. “If you take a breath or think about any of these cases, you’re going to fall behind.”
Cigna created what one of Day’s managers referred to as a “productivity dashboard,” which tracked and shared how quickly doctors could process medical claims. Although this tactic is used in other places like service and warehouse industries, critics have noted that the stakes are too high in the health care industry for this practice, as human lives could be in danger if mistakes are made. It’s for this reason that Walgreens discontinued the use of this practice for their pharmacists.
Day said that Cigna set unrealistic metrics, often requiring that doctors approve or deny complex cases in a matter of minutes. “Medical directors would message me and say, ‘We can’t do these cases in four minutes. Not if you want to do a good job,’” said Day.
After years of addressing her concerns with Cigna, and after seeking therapy to treat her depression brought on by this situation, Day made the difficult decision to retire from Cigna in 2022.
Processing medical claims quickly is nothing new for Cigna. Last year, ProPublica found that Cigna was using a computer algorithm called PXDX which allowed doctors to spend an average of just 1.2 seconds reviewing a case.
This report makes a compelling case that Cigna prioritizes speed over doing right by their patients, a tactic that boosts their profits while denying coverage for consumers in need. CQC urges lawmakers and regulators to hold insurers accountable for improper, ill-vetted, and unfair denials.
