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Sacaramento: A federal lawsuit alleges that medical health insurance big Cigna used a pc algorithm to robotically reject lots of of 1000’s of affected person claims with out analyzing them individually as required by California legislation.
The category-action lawsuit, filed Monday in federal court docket in Sacramento, says Cigna Corp. and Cigna Well being and Life Insurance coverage Co. rejected greater than 300,000 fee claims in simply two months final 12 months.
The corporate used an algorithm known as PXDX, shorthand for ”procedure-to-diagnosis,” to establish whether or not claims met sure necessities, spending a mean of simply 1.2 seconds on every evaluation, in keeping with the lawsuit. Large batches of claims had been then despatched on to docs who signed off on the denials, the lawsuit mentioned.
“Counting on the PXDX system, Cigna’s docs immediately reject claims on medical grounds with out ever opening affected person information, leaving 1000’s of sufferers successfully with out protection and with surprising payments,” in keeping with the lawsuit.
In the end, Cigna performed an “unlawful scheme to systematically, wrongfully and robotically” deny members claims to keep away from paying for medical mandatory 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 checks after Cigna denied their claims.
The lawsuit accuses Cigna of violating California’s requirement that it conduct “thorough, honest, and goal” investigations of payments submitted for medical bills. It seeks unspecified damages and a jury trial.
Cigna “makes use of the PXDX system as a result of it is aware of it is not going to be held accountable for wrongful denials” as a result of solely a small fraction of policyholders enchantment denied claims, in keeping with the lawsuit.
In an announcement, Cigna Healthcare mentioned the lawsuit “seems extremely questionable and appears to be based mostly solely on a poorly reported article that skewed the info.”
The corporate says the method is used to hurry up funds to physicians for frequent, comparatively cheap procedures by means of an industry-standard evaluation course of just like these utilized by different insurers for years.
“Cigna makes use of know-how to confirm that the codes on among the most typical, low-cost procedures are submitted accurately based mostly on our publicly out there protection insurance policies, and that is executed to assist expedite doctor reimbursement,” the assertion mentioned. “The evaluation takes place after sufferers have acquired therapy, so it doesn’t lead to any denials of care. If codes are submitted incorrectly, we offer clear steerage on resubmission and how you can enchantment.”
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Sacaramento: A federal lawsuit alleges that medical health insurance big Cigna used a pc algorithm to robotically reject lots of of 1000’s of affected person claims with out analyzing them individually as required by California legislation.
The category-action lawsuit, filed Monday in federal court docket in Sacramento, says Cigna Corp. and Cigna Well being and Life Insurance coverage Co. rejected greater than 300,000 fee claims in simply two months final 12 months.
The corporate used an algorithm known as PXDX, shorthand for ”procedure-to-diagnosis,” to establish whether or not claims met sure necessities, spending a mean of simply 1.2 seconds on every evaluation, in keeping with the lawsuit. Large batches of claims had been then despatched on to docs who signed off on the denials, the lawsuit mentioned.
“Counting on the PXDX system, Cigna’s docs immediately reject claims on medical grounds with out ever opening affected person information, leaving 1000’s of sufferers successfully with out protection and with surprising payments,” in keeping with the lawsuit.
In the end, Cigna performed an “unlawful scheme to systematically, wrongfully and robotically” deny members claims to keep away from paying for medical mandatory 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 checks after Cigna denied their claims.
The lawsuit accuses Cigna of violating California’s requirement that it conduct “thorough, honest, and goal” investigations of payments submitted for medical bills. It seeks unspecified damages and a jury trial.
Cigna “makes use of the PXDX system as a result of it is aware of it is not going to be held accountable for wrongful denials” as a result of solely a small fraction of policyholders enchantment denied claims, in keeping with the lawsuit.
In an announcement, Cigna Healthcare mentioned the lawsuit “seems extremely questionable and appears to be based mostly solely on a poorly reported article that skewed the info.”
The corporate says the method is used to hurry up funds to physicians for frequent, comparatively cheap procedures by means of an industry-standard evaluation course of just like these utilized by different insurers for years.
“Cigna makes use of know-how to confirm that the codes on among the most typical, low-cost procedures are submitted accurately based mostly on our publicly out there protection insurance policies, and that is executed to assist expedite doctor reimbursement,” the assertion mentioned. “The evaluation takes place after sufferers have acquired therapy, so it doesn’t lead to any denials of care. If codes are submitted incorrectly, we offer clear steerage on resubmission and how you can enchantment.”
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