A SECOND OPINION
This space is for our physician members to speak their minds freely on both medical or non-medical issues of the day and respond to the opinions of others . The GLMS Editorial Board reserves the right to choose what will be published . Please note that the views expressed in A Second Opinion or any other article in this publication are not those of the Greater Louisville Medical Society or Louisville Medicine .
DENY THIS , YOU %$&#@!!
by MARY BARRY , MD
Did someone mention obstacles ?
Perhaps they were thinking of the potential mini-strokes that legions of primary care doctors risk when reading denial letters from insurance companies .
Cigna , for instance , has an automated system called PXDX ( I translate this as “ piss on their diagnosis ”) that spews out medical claim denials every 10 seconds on the grounds that they are “ not medically necessary .” Actual MDs are said to approve these and are expected by their employers to meet this assembly line rate . In all my years of tilting at insurance windmills , I only managed to speak to an actual MD at Cigna maybe twice – and both times the person had practiced in a specialty far removed from the patient ’ s problem that I was trying to solve . Humana had more approachable higher-level naysayers , at least ; the advantage of being local held true quite often . The rest of the commercial insurers were all irritating to deal with . Dealing with government insurance – Medicaid and Medicare – was more straightforward . So long as you had coded it properly , you had a chance .
But this claptrap of algorithmic denials every 10 seconds is a new low , one that naturally the insurance moguls crow about . Per this March 25th ProPublica article , 1
“ The company has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file , leaving people with unexpected bills , according to corporate documents and interviews with former Cigna officials . Over a period of two months last year , Cigna doctors denied over 300,000 requests for payments using this method , spending an average of 1.2 seconds on each case , the documents show . The company has reported it covers or administers health care plans for 18 million people .”
The Cigna ads however say , “ You ’ ll put the world on hold till her fever breaks .” “ You ’ ve always prioritized the health of your family . Now you have a partner .” But does a real partner deny your message without even reading it ?
The sheer arrogance of denying people much-needed care – actual human beings whom they have contracted to help with insurance bills , whose checks they cash every single month – without even reading the case details is stunning . Yet I am not surprised , as I learned cynicism early in the health insurance game .
Just three doctors noted in the article that over a two-month span , they together denied 264,000 claims . Typically , only one in five denied claims for the Cigna Medicare Advantage plans is appealed – but the success rate in overturning each denial is more than 80 %. That stat alone should indicate that something is rotten in the Cigna cyber world . That stat indicates that patients are paying twice : first with their premiums , then with the individually denied claims . That sounds like the cheatin ’ sort of partner to me .
Luckily , however , someone in Congress still reads . Rep . Cathy McMorris Rodgers ( R-Washington ), chair of the House Committee on Energy and Commerce , in May asked Cigna for corporate documents relating to the deny-without-even-looking PXDX . 2 California , Maryland and Washington state insurance regulators have raised objections as well and have begun investigations . Her letter from the Committee asked for “ copies of all memoranda analyzing the
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