SACRAMENTO, Calif. — A federal lawsuit alleges that medical insurance large Cigna used a pc algorithm to robotically reject lots of of hundreds of affected person claims with out analyzing them individually as required by California regulation.
The class-action lawsuit, filed Monday in federal courtroom in Sacramento, says Cigna Corp. and Cigna Health and Life Insurance Co. rejected greater than 300,000 cost claims in simply two months final yr.
The firm used an algorithm referred to as PXDX, shorthand for ”procedure-to-diagnosis,” to establish whether or not claims met sure necessities, spending a median of simply 1.2 seconds on every evaluate, in response to the lawsuit. Huge batches of claims had been then despatched on to docs who signed off on the denials, the lawsuit mentioned.
“Relying on the PXDX system, Cigna’s doctors instantly reject claims on medical grounds without ever opening patient files, leaving thousands of patients effectively without coverage and with unexpected bills,” in response to the lawsuit.
Ultimately, Cigna performed an “illegal scheme to systematically, wrongfully and automatically” deny members claims to keep away from paying for medically needed procedures, the lawsuit contends.
Connecticut-based Cigna has 18 million U.S. members, together with greater than 2 million in California.
The lawsuit was filed on behalf of two Cigna members in Placer and San Diego counties who had been compelled to pay for assessments after Cigna denied their claims.
The lawsuit accuses Cigna of violating California’s requirement that it conduct “thorough, fair, and objective” investigations of payments submitted for medical bills. It seeks unspecified damages and a jury trial.
Cigna “utilizes the PXDX system because it knows it will not be held accountable for wrongful denials” as a result of solely a small fraction of policyholders attraction denied claims, in response to the lawsuit.
In an announcement, Cigna Healthcare mentioned the lawsuit “appears highly questionable and seems to be based entirely on a poorly reported article that skewed the facts.”
The firm says the method is used to hurry up funds to physicians for frequent, comparatively cheap procedures by an industry-standard evaluate course of much like these utilized by different insurers for years.
“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 assertion mentioned. “The review takes place after patients have received treatment, so it does not result in any denials of care. If codes are submitted incorrectly, we provide clear guidance on resubmission and how to appeal.”
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