Reports that insurance companies are refusing to pay insurance claims in large numbers in a system that allows computers to check patient diagnostic records
Cigna, one of America's largest insurance companies, built a system that allows company doctors to immediately reject insurance claims without looking at patient charts, resulting in 300,000 insurance claims in just two months. has refused to pay, reports non-profit news media ProPublica.
How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them — ProPublica
In the United States, insurance laws and regulations differ from state to state, but basically, before paying insurance claims, whether the insurance company's doctor should check the patient's diagnosis results and medical charts and pay insurance claims. is determined to be considered.
But at Cigna, medical directors don't look at patient records or make medical decisions. Instead, an algorithm checks patient diagnostic records and builds a system to consider reimbursement. It is said that there is. According to a doctor who was a former employee of Cigna, it is possible to refuse insurance payments by simply clicking and sending, and it is possible to process 50 times in 10 seconds at a time. Of course, not all insurance claims are processed by this algorithm, but it seems that it is unknown how many of the claims are processed by the algorithm and how many of them are rejected.
This system is called 'PXDX' and was developed by a former pediatrician more than 10 years ago. Insurance claims are typically reviewed by a doctor, but reviewing a large number of claims is costly. Therefore, for small claims, using the system can reduce costs.
A doctor at Cigna says he has dismissed 121,000 claims in just two months using PXDX. Another doctor dismissed more than 80,000 claims in the same period, ProPublica reports.
Former California Insurance Commissioner Dave Jeans said, 'I don't think it's compliant with state law that it only takes a few seconds to check a medical record. I think we should at least look into it. I am,” he commented.
An anonymous witness, a former Cigna executive, said, 'We were aware that PXDX might be legally gray. We sent the PXDX proposal to the legal department, and the legal department said it was OK. I sent it back, ”he said, and since then, some executives have questioned whether it is legal. Also, two doctors who were former employees of Cigna said, 'PXDX is unfair to patients.'
On the other hand, Cigna said, “ProPublica’s coverage is biased and incomplete. I will,” he replied in writing.
Emergency doctor Nick Van Terhayden, who was diagnosed with vitamin D deficiency by a blood test but was refused to pay $350 (about 46,000 yen) for the blood test by PXDX, said Cigna's insurance payment. We have referred the rejection to an independent external investigation. Then, seven months after the blood test, an external doctor decided that the blood test was medically necessary and appropriate.
'It's not good medicine, it's not caring about the patient,' Terhayden said. I can understand what Cigna is doing mentally, but as a doctor, I don't understand it.
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