After spending hours with patients deciding what tests or treatments are most appropriate, guess how many seconds it takes for an insurance doctor to reject the claim?
Like most clinicians, I find myself dealing with an ever-increasing pile of prior authorizations and insurance denials for tests or treatments. During the peak of the COVID pandemic there seemed to be some respite, but in the past year the barriers to giving timely and appropriate care have risen even higher. In case you thought that insurers were carefully and painstakingly reviewing your notes and letters of appeal, a recent article from ProPublica shines a bright light on the denial process that’s been developed and refined for one corporate insurer, Cigna. This company that covers 18 million lives, has constructed a computer system, PxDx, that permits its physicians to “instantly reject a claim on medical grounds without opening the patient file. A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments.” Cigna physicians then click to approve the denials in batches, spending an average of 1.2 seconds on each file. The process has saved Cigna many millions of dollars and is so fiendishly efficient that one physician was able to reject 121,000 claims in the first two months of 2022.
What you can do:
1. Know that most states have health insurance regulatory bodies.
In Maryland, we have the Maryland Insurance Administration that requires that “insurance company doctors be objective and flexible when they sit down to evaluate each case.” Bringing inappropriate denials to the attention of the MIA is relatively easy for patient or provider.
2. Work with professional societies that are engaged with clinical practice issues for your specialty to bring these kinds of practices to the attention of policy makers.
3. Encourage patients to register complaints with their insurers, state agencies, and legislators.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.