In March 2023, ProPublica brought to light a laundry list of allegations about Cigna’s claim denial process, essentially stating that doctors on Cigna’s medical review staff are automatically denying medical claims without opening files. Insurance company doctors are generally tasked with examining patient records and reviewing coverage policies before denial status can be reached. Yet, over the course of two months last year (2022), Cigna doctors denied over 300,000 requests for payments using their internal “PXDX” review — a review method that allows them to spend an average of 1.2 seconds on each case.
This auto-deny methodology still leaves room for patients and providers to appeal, but appeals are such large hassles that Cigna bets people won’t take the time. “In one corporate document,” Propublica journalists wrote, “Cigna estimated that only 5% of people would appeal a denial resulting from a PXDX review.”
That’s right. Only 5%. That means Cigna is arbitrarily denying claims without reviewing them and is only held accountable by 5% of their victims.
Cigna pushes back on these claims, citing that their PXDX review only captures claims that were already missing information or had an information mismatch. But sadly this isn’t the first Cigna claim misconduct issue brought to light. A proposed class-action lawsuit alleges Cigna intentionally underpaid medical claims as far back as 2017. The lawsuit challenges that Cigna failed to apply the appropriate MultiPlan contracted rates to claims — therefore underpaying several providers and disregarding their rightful reimbursement.
But Cigna is likely not the only insurance company that isn’t consistently working in your patients’ or your providers’ best interests. The best way to stay on top of possible issues from your insurance payers is to monitor your payer relationships and contracts, prevent denials, and work every denial that comes through your office.
What if you don’t have the time or resources to increase your team’s workload? That’s what Cigna and other payers are counting on, but you can stop the cycle. Cigna’s 5% appeal could be accurate overall, but with Rivet, you can appeal 98% of all of your denials. You can work 70% more denials on average than what you’re doing now and rescue your revenue.