Cigna health insurance has an efficient system to process claims quickly and easily: they just ask their medical reviewers to outright reject most claims. This streamlined system allows a doctor to review the claim and reject it without even opening the file. In the 6 ½ minutes it took me to read the investigative report in Propublica, 472 people had claims rejected by Cigna health insurance.
In most states, the law mandates that a doctor must review all medical claims submitted to insurance. Medical directors are expected to read the patient’s file, familiarize themselves with that person’s coverage and determine if the claim is covered and to what extent. This work is now done by an algorithm which looks for mismatches between codes and tests ordered and outright rejects them. Those rejections get sent to the medical director who can batch sign them. It takes the doctor 10 seconds to reject 50 claims.
This system has been in place for over 10 years and other insurance companies use a similar system.
The only way to get your legitimate claim reviewed is to file an appeal. The process is time consuming, requires that the insured make calls, wait on hold for long periods of time, re-submit paperwork and hope for the best.
With private, for-profit insurance companies ruling the healthcare industry, you need to buy insurance but the corporation you buy the insurance from is not regulated to assure that they will provide you any coverage. They can just take your money, promising healthcare coverage, but then refuse to pay what they said they’d cover. It’s legal fraud and theft.