Cigna Sued Over Algorithm Allegedly Used To Deny Coverage To Hundreds Of Thousands Of Patients

Cigna owns the PBM Express Scripts – according to this article  Express Script is the SECOND LARGEST PBM,  HOWEVER, recent announced merger between Humana & United Health, suggests that merger will push Express Script down to THIRD PLACE.

One of the basics of the practice of medicine is starting, changing, stopping a pt’s therapy. While Cigna is just denial payment for a particular therapy, not technically stopping the pt’s therapy, but few people can afford to pay “rack rate” for some fairly expensive tests and/or procedures. Some would argue that denying payment for a expensive test or procedure is basically stopping a pt’s therapy because the pt has a health insurance policy – which is technically a contract – and generally a contract between two parties and party is paying money for payment for necessary medical services and the other party ends up playing games and finding excuses to not fulfill the terms of the contract. Some would consider that FRAUD.

According to this lawsuit, this is not just a few examples, but involves denial of care to hundreds of thousands of pts and the denials are being done on a wholesale level.

Cigna Sued Over Algorithm Allegedly Used To Deny Coverage To Hundreds Of Thousands Of Patients

The software system allows claim rejections without doctors ever opening patient medical records, according to the lawsuit.

Cigna, the healthcare and insurance giant, was hit with a lawsuit on Monday that alleges the company systematically rejects claims in a matter of seconds, thanks to an algorithmic system put in place to help automate the process—further raising questions about how technology could harm patients as more healthcare organizations look to embrace AI and other new tools.

The suit, which was filed in California and is seeking class action status, was brought forth by a pair of plaintiffs who were denied coverage by Cigna. One plaintiff, Suzanne Kisting-Leung, was referred for an ultrasound because of a suspected risk of ovarian cancer. Another, Ayesha Smiley, had been tested for a vitamin D deficiency at the order of her doctor.

The health insurer’s digital claims system, called PXDX, is an “improper scheme designed to systematically, wrongfully, and automatically deny its insureds medical payments owed to them under Cigna’s insurance policies,” the complaint alleges.

After the lawsuit was filed Monday, Cigna defended the software system. “PXDX is a simple tool to accelerate physician payments that has been grossly mischaracterized in the press,” spokesperson Justine Sessions said in a statement. “The facts speak for themselves, and we will continue to set the record straight.”

The suit follows a Propublica investigation in March that detailed Cigna’s software system for approving and denying claims in batches. The algorithm works by flagging discrepancies between a diagnosis and what Cigna considers “acceptable tests and procedures for those ailments,” according to the lawsuit.

Over two months last year, the company denied more than 300,000 claims, spending an average of 1.2 seconds on each claim, Propublica reported. While medical doctors signed off on the denials, the system didn’t require them to open patient medical records for the review. The complaint says that this violates a California competition law for unfair and fraudulent business acts. The suit also alleges the system violates the state’s insurance code for failing to adopt a “reasonable standard” for processing claims.

The complaint comes as a boom in artificial intelligence and other advanced technology has raised questions about the future of work, potentially upending every industry from advertising to insurance. Healthcare is one sector where a high-tech makeover could both be beneficial—aiding doctors in filling out burdensome paperwork or helping narrow down diagnoses—but also fraught, due to issues of patient privacy, access to care and the high cost of medical bills.

Cigna isn’t alone in adopting new tech to remake its processes. In April, Google’s cloud division unveiled new tools for healthcare claims processing that uses AI to organize data and streamline decision-making. Blue Shield of California and Bupa are among the companies using the tool.

The firm representing the plaintiffs, Malibu, California-based Clarkson Law, has previously taken on tech giants when it comes to AI. Earlier this month, the firm filed lawsuits against OpenAI, the company behind ChatGPT, and Google, which has its own generative chatbot called Bard, for allegedly stealing the data of millions of people—including artists and writers who copyrighted their works—to train and build their AI products.

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