How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them

[Jason]

How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them

WWW.PROPUBLICA.ORG

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Internal documents and former company executives reveal how Cigna doctors reject patients’ claims without opening their files. “We literally click and submit,” one former company doctor said.

 

[Ricofoley]

There was a thread on the forbidden site a while back where a doctor found out that a doctor working for one of these insurance boards used to be a surgeon until he put in somebody's hip replacement completely backwards.

[Jwheel86]

One of the bigger disability advocates is filing a complaint against Carefirst for denying his life saving drug after taking 13 days to review his prior auth, and only giving him 1hr 38min to send lab results which Carefirst had for years.

[finaljedi]

I remember when I worked appeals at Anthem all State of Kentucky appeals had to be signed by the medical director for the Kentucky plans.  His signature was saved on all the templates we had for claims from Kentucky, I don't think he reviewed very many...

 

Every time one of these stories comes out I just kind of look back at the nearly 4 years I spent working on that side and figure "yeah, this checks out"  One of the first things they told me when I started in appeals was "We don't care about legal threats, we get sued all the time, if someone threatens to go to the media, escalate that to the manager immediately"

[unogueen]

This is more insidious than just malice. This seems to indicate market value has usurped even the simple hippocratic oath.

[Spawn_of_Apathy]

17 hours ago, unogueen said:

This is more insidious than just malice. This seems to indicate market value has usurped even the simple hippocratic oath.

that happened the moment America was introduced to the HMO system. 

[TwinIon]

Having a computer automatically match diagnoses with obvious procedures makes sense, allows them to rubber stamp things without a doctor needing to review every single thing. However, it also seems like they're doing the opposite, which should probably just be the first step in the process. If a request comes through that the computer didn't immediately match with a known test or procedure, it shouldn't be automatically rejected, just sent on to an escalated review.

 

It seems to me that they're effectively offloading that secondary review to their customers and their doctors. I bet the working assumption is that if something is really important then people will contest the rejection or otherwise follow up in some way. That way they don't need to put any real man hours into looking at any given patient file unless something gets through this kind of patient induced secondary screening.

 

So yeah, turns out making healthcare into a for-private enterprise with a captive customer base that has few (if any) real choices is a bad idea that leads to bad outcomes.

[Zaku3]

It leads to the positive (outcome) of cash money for the company. 

 

My incident with Corey was eye opening. I proactively don't wanna live in a country that proactively profits off of my (also other humans) misery. It was 6ish thousand for what happened. (Cancer throughout his body) The original estimate was 9-14k if surgery could be done and if it was successful or not. One of my old love interests told me I know it's why she has insurance on all of her dogs and cats. I no longer recognize that as a "normal" thing we as a society should be doing. That sentiment applies to dogs, cats, humans, etc.

 

Edit: I was wondering why all the drs and nurses were squimish about pricing. Combo of getting push back from family and cope so they can keep coming to work and not feel bad about what they do from a fiancial sense.