18 ms·

Cigna saves millions by having its doctors reject claims without reading them

564 points by metadat 4y ago

babbledabbler 4y ago
Somebody should make an AI service that automatically files appeals. I suspect that the cost of the appeals process would negate the savings they make from auto-denying claims.
stathibus 4y ago
This reminds me of the US patent approval system. There are too many claims to properly vet them all, so just "click and submit" and only put effort into the ones that come back to complain. (Except the PTO is biased toward approval and not rejection, of course.)
- AnthonyMouse 4y ago
  Not exactly. The US PTO rejects a large proportion of patent claims. It can be quite expensive / time consuming to get a US patent as an individual inventor. But you can appeal the rejections, and large corporations and patent trolls have staff attorneys who do that all day long, so then tons of garbage patents get approved too.
woohoo7676 4y ago
This has been happening to me for the past several months. 1. Cigna will not tell you for any reason, why the claim is denied 2. Reps will not help at all other than "Oh I see the issue, will reprocess" which often just results in another denial 3. The issue that a helpful rep finally disclosed: Cigna's own claim form for providers has a box that is overloaded for procedure code and equipment code; apparently the CPT code for therapy is the same as the equipment code for injections. So one claim processor decided that the claim was for injections and denied it. Then every subsequent claim has been denied under the same reason. 4. At this point the only option for me is for my provider to appeal every single claim (which takes months), as this is the only way to get someone to actually read the claim and make an intelligent decision. An absolute nightmare :(
- kurikuri 4y ago
  I always wonder if small claims court could be somewhat viable. In the instances where I’ve fought and gotten approval, I’ve spent my own time, my own money, and had my health deteriorate. Ideally, I’d like to be compensated for the time I’ve spent defending myself to this company, and I’d like some form of remuneration (somewhat for retribution, somewhat as a negative incentive to the company) for my now diminished health…
  - Kye 4y ago
    There needs to be something like the CFPB for health care. I couldn't get an actual human to acknowledge me when dealing with PNC when they ate up my bank, but one CFPB complaint got them to do exactly what I asked. That way you never get to the point of burning time, money, and health because they're afraid of action from the agency.
    - lotsofpulp 4y ago
      It would be the state’s insurance regulator, although do not know if they are as effective as CFPB. Financial issues tend to be much less complicated than health issues, and usually just a result of understaffing and underinvesting in customer service.
    - woohoo7676 4y ago
      Great idea - agreed we need an agency to go to that has some teeth, as the insurance co's will never be afraid of individuals.
  - firstlink 4y ago
    If you have health insurance from your employer, it's probably covered under ERISA. This is federal, so no help from your state insurance agency and no small claims, and I have found that there are few lawyers who will touch it even in a large city.
- indymike 4y ago
  > 1. Cigna will not tell you for any reason, why the claim is denied Of course not. Fight fire with fire. Get care providers to sign a letter to Cigna saying the procedure is medically necessary Going through the process will not work and will go slow. But putting them on notice by having licensed, local care providers say something is medically necessary and urgent will work almost 100% of the time.
blakesterz 4y ago
“We thought it might fall into a legal gray zone,” said the former Cigna official, who helped conceive the program. “We sent the idea to legal, and they sent it back saying it was OK.” Reading this article is just maddening. I've been dealing with different insurers for the past 7 years or so, and it's my experience they must all do something similar. Anyone with any kind of serious health condition is regularly driven CRAZY dealing with insurance. It's just an insane and broken system.
- kurthr 4y ago
  Wife is a nurse. Required surgery for lifesaving/severe disability (inherited congenital, killed her father). Insurance was Aetna and Hospital Self Insured. Surgery recommended by world class surgeon she worked with. Finally pre-approved on 3rd appeal after 8 months and 150pages of documentation of every piece of every single communication (who, when, response, expected next contact) only weeks before surgery scheduled >6 months before. First rejection was automatic, second was revealed to be a dermatologist, third was a gynecologist. (They really hated that we figured out who the person was, their specialty, the state they worked in, and pending disciplinary actions). Standard answer is we can't tell you why you were rejected (code only) because the criteria are from a third party and their review document is proprietary. When you find an online leaked document with the same code it says "unnecessary cosmetic surgery". Wrong contact numbers are provided, people go on vacation and do not respond for weeks, "that person doesn't work here". If you're not a professional in the field with time on your hands and a detail oriented A-hole, you will be denied anything expensive that isn't considered immediately lifesaving at a trauma ICU recommended by the attending. After pre-approved surgery with excessive blood loss and an extra 12 hours in recovery... Overcharge/All-claims-denied. Multiple appeals until involving Hospital CFO who agrees to split the extra (self-insured) cost of the insurer and get the final insurance reimbursement check... it is $3k less than promised (hospital paid the correct amount). Surgeon was going to start charging late fees and interest or send it to collection after 4 months. Is it worth fighting any more? No.
  - anigbrowl 4y ago
    Standard answer is we can't tell you why you were rejected How did you find out about the automatic rejection/identity of the reviewers?
dafelst 4y ago
Privatized health care as a person's sole option for care is an absolute dystopian nightmare. Any system that requires balancing human suffering against profitability is inevitably going to optimize for profitability. The fact that this is even a thing is mind boggling.
- xwdv 4y ago
  Public health care can be similarly dystopian in other ways: Very long wait times due to limited resources, subpar medical care, limited prescription options and drugs, beauracracy. No matter what society you live, the advice is the same: try not to get sick.
  - PicassoCTs 4y ago
    Ah, yes, have a privatized public sector, use the gained funds to lobby in other countries, pushing a ideology that destroys public sector/services, use the result of ones own actions to push the conversion to more privatized public sector. The ultimate glider gun ideology.
  - weaksauce 4y ago
    > Very long wait times due to limited resources, subpar medical care, limited prescription options and drugs, beauracracy. those are all there because the people that created the system did not think paying for it was good enough. it doesn't have to be that way. and even with wait times being long you still eventually get it. in the privatized system if you are poor and have bad health care you don't get it at all.
  - harshalizee 4y ago
    I moved from a third world country with both socialized and private healthcare, to the United States. I pay vastly more for worse healthcare than anywhere I've lived. The fact that you, your doctor can agree that a certain procedure is required, only to be denied by a third party with no medical qualification is absolutely dystopian.
    - 4y ago
lotsofpulp 4y ago
And still Cigna’s profit margins are low single digit percentages. https://www.macrotrends.net/stocks/charts/CI/cigna-group/profit-margins https://www.macrotrends.net/stocks/charts/CI/cigna-group/pro... Wonder what premiums and out of pocket maximums would have to be if there were fewer denials.
- OrvalWintermute 4y ago
  If they are paying out huge sums to their c-suite, giving them stock left and right, and enriching the company through stock schemes or dividend payouts, unjustly, perhaps their compensation shouldn't be so rich? https://www.statnews.com/2022/05/12/health-insurance-ceos-raked-in-record-pay-during-covid/ https://www.statnews.com/2022/05/12/health-insurance-ceos-ra...
  - candiddevmike 4y ago
    C-suite, board members, a bunch of "foundations", probably some for-profit contracting services for IT and accounting (also managed by the c-suite, probably). Unraveling health insurance admin costs is probably similar to Panama Papers level of financial engineering, especially after the ACA capped profit margins, the companies just turned to malicious compliance.
    - lotsofpulp 4y ago
      If you look at the 10-K for any of the 7 publicly listed health insurers, administrative cost increases are minuscule compared to healthcare expenditures. You can get rid of half the employees and cut everyone’s pay by half, and it won’t make much difference. I think the US’s biggest problem in healthcare is liability. Every entity is spending so many resources on making sure that they do not get blamed in the event there is a lawsuit, because the damages are huge. In countries with taxpayer funded healthcare, this liability issue is much less because you are dealing with the government only and suddenly liability and damage amounts are reduced.
  - vkou 4y ago
    I think we can just go a step further and kill their entire toxic business model. After decades of observing how it behaves, it should be pretty clear that it's always going to devolve down to privately-ran death panels.
prophesi 4y ago
I wish I was surprised. Automated decision-making with little to no human oversight is the dream of risky bets (policing, insurance, loans, etc).
hestefisk 4y ago
This is the reason we need universal public healthcare.
- luckylion 4y ago
  That won't help you there. Germany's public healthcare system denies plenty of things too, and will only pay for treatment when you sue (or know someone who works there). Germany's private healthcare system on the other hand is usually better (I'm sure there are exceptions and some insurance company that sucks).
  - hestefisk 4y ago
    You can have good public healthcare without the need of the notion of 'claims'. The Scandinavian healthcare system is a good example (https://en.wikipedia.org/wiki/Healthcare_in_Denmark https://en.wikipedia.org/wiki/Healthcare_in_Denmark).
    - firstlink 4y ago
      > The central government plays a relatively limited role in health care in Denmark. So the exact opposite of what people usually mean when they say they want public healthcare. Words mean something.
      - theossuary 4y ago
        Public healthcare means health care paid for via public funds, nothing more. Many public health care systems aren't entirely centralized, even though they use public funds. For example even the UK's NHS has regions with allocated budgets they manage based on the number of patients they see, which they then spend as they see fit. You're trying to attach your biases and assumptions onto an amorphous phrase, and then pretend others are using it wrong because they don't have the same expectations. That isn't reasonable.
      - hestefisk 4y ago
        I am of Danish origin and stating that the central government has a limited role in healthcare is just downright incorrect. The Ministry of Health (Sundhedsstyrelsen) sets the budget, determines national practices, manages the public health insurance scheme, and manages the list of approved medicines. Yes, execution of healthcare is with the regions, but there has been a significant increase in centralisation of healthcare since the “amter” were disbanded.
netmonk 4y ago
[dead]
loeg 4y ago
> His claim was just one of roughly 60,000 that Dopke denied in a single month last year 60,000 / 20 workdays in a month / 8 hours in a workday => this guy rejected about 375 claims per hour, on average. Over six claims a minute. He spent less than 10 seconds on each claim, for a full month of work time.
- Centigonal 4y ago
  Less than 10s/claim is actually an upper bound, since chances are there's meetings, coffee breaks, and other overhead.
- prepend 4y ago
  I mean supposedly the doctor also approved some so their review rate is even higher.
- SapporoChris 4y ago
  "A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments." "Cigna said its review system was created to “accelerate payment of claims for certain routine screenings,” This sounds like simple automation with an error rate that is acceptable by Cigna. Of course it's not acceptable to anyone wrongfully denied a claim. Now that's an issue I don't see in the article. How many claims were wrongfully denied? I can't get worked up about the situation when critical information is missing.
  - ahi 4y ago
    They are not legally allowed to automate this. These cases MUST be reviewed by qualified medical personnel.
  - magicalist 4y ago
    > Now that's an issue I don't see in the article. How many claims were wrongfully denied? Well gee, to actually estimate that you'd need a medical expert to review the claims.
  - IG_Semmelweiss 4y ago
courseofaction 4y ago
Jail the executives.
- RainbowFriends 4y ago
  Revoke the medical licenses of the doctors who rubber stamp the denials.
  - dragonwriter 4y ago
    In addition, states (as the pirnary regulators of insurance) should adopt a rule that if an insurer has a policy which directs, incentivizes, or which managenment knows or should reasonably know results in denials without good faith review, the state then has a cause of action against the insurer for damages of equal to triple the amount originally denied without appropriate review (whether or not later paid), and will, if necessary, pierce the corporate veil to recover it and, separately, each medical reviewer who is found to have denied a claim without good faith review shall be fined an amount equal to the value of claims so denied and prohibited (regardless of whether their medical license may later be restored) from being responsible for medical review of insurance claims in the state in the future.
ncallaway 4y ago
I genuinely think every health insurance denial should have to come from a named doctor at the health insurance company who is personally and professionally liable for the health outcomes from a denial. Deny someone life-saving care without a sound medical reason? That’s a malpractice lawsuit and a potential loss of their medical license.
- theGnuMe 4y ago
  There's some doc on twitter who was denied by insurance and he filed a board complaint against the insurance doc claiming malpractice. I think he won.
  - d1str0 4y ago
    Know any more details? This seems rather promising.
    - theGnuMe 4y ago
      https://twitter.com/generalorthomd/status/1632074816378507264 https://twitter.com/generalorthomd/status/163207481637850726...
    - IG_Semmelweiss 4y ago
      the claim denier worked for insurance. he had a complaint on file for entering a hip replacement backwards the tweeter thread shows devastating images . the point is that a provider like that, has no business denying coverage. plus apparently he was not board cert and other issues from lapses in licensing
  - ncallaway 4y ago
    Yep, basically we should make it much easier to identify the specific doctor that is responsible for the denial (to make them easier to sue personally, and discipline professionally), and we should make the liability for such a denial extremely explicit.
- kube-system 4y ago
electrondood 4y ago
For anyone who is against government regulation... this is another perfect example of the kind of perverse financial incentives unregulated capitalism results in. Blanket denial without consideration lowers your costs as an insurance provider, because it acts like a filter on people who care enough to appeal repeatedly.
- whatthesmack 4y ago
  This is not unregulated capitalism. This is crony capitalism or corruption. It is government regulation that allows a monopoly of large corporations to remain the powerful health insurance companies they are, and ObamaCare gave them even more power. If this was a free, unregulated market, healthcare in the US would be cheaper.
deleted 4y ago
[deleted]
mdmglr 4y ago
Maybe to speed things up patients can opt to have ChatGPT read the claim and make a decision. /s
- readme 4y ago
  it would probably benefit patients
  - Ekaros 4y ago
    AIs are wrong at least some of the time... That means they will approve some claims. Not deny all of them.
pontifier 4y ago
Automatic rejection is a tactic used by all sorts of con artists. If they say no and you never come back then they don't have to worry about you anymore.
lostmsu 4y ago
I am surprised commenters here did not read into the nuance: > A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity. Before grabbing the pitchforks, it is important to be sure if their policy is reasonable or not. Whose fault is it if doctors ask clients to perform expensive tests, because they can't be bothered to actually think and figure out what test would be the most optimal? Now even if the doctors really overprescribe tests, I don't think the client should be responsible. Instead, the insurance should pay, but kick the doctor out of their network.
- sidlls 4y ago
  I don’t think we should trust the soundness of their algorithm. I’ve worked in the healthcare space before, and the perverse incentives involved should make everyone extremely skeptical of insurance companies’ motivations, procedures, and algorithms.
  - lostmsu 4y ago
    From the description it sounded like something trivial. E.g. given the diagnosis, there might be a cheaper known way to get to it. I am a layman, but for instance that could be ordering an MRI when an ultrasound would suffice.
- salawat 4y ago
  Fuck that. You know what that incentivizes? Not testing at all. You know what that leads to? Bad outcomes. I'm all for selection pressure toward more efficacious, less invasive, less dangerous tests. Writing an insurer a blank check to blanket deny millions of claims without checking or reading up though? Nah. That's profiteering. You want to run that algo in parallel and dift through the claims that would change, individually weeding out the actual false positives? Kosher. Just YOLO'ing it on prod and trottingbit out in front of investors? Hell no.
- soared 4y ago
  It’s insane to trust an insurance company to make healthcare decisions. I was denied an MRI when I tore my hamstring off the bone, and so my doctor had zero info on what my treatment options should be. I went to physical therapy when I possibly should have had surgery. I’d so much rather 10% of people overpay for unnecessary tests than the other 10% of people be denied potentially necessary care.
vfclists 4y ago
There a few points to be made here: 1. The doctors who signed of on those batches should be sued for medical malpractice and negligence. Where is the AMA on this issue? 2. Why are the tests so expensive? All it requires is to add some chemicals to the blood sample or whatever and see if it changes color or something? $1000 of dollars? 3. Isn't there a trust relationship between Cigna and the doctors who authorize the tests? Does Cigna believe that some of its doctors have a relationship with the testing companies where they receive kickbacks for authorizing the tests? 4. The patients whose tests were signed of in batches must file a class action lawsuits against each doctor separately and Sigma. The doctors and Cigna are colluding in medical fraud. Even if subsequent indepth evaluations indicate that declining a tests was justified they should still be sued as they signed off the tests without actually doing the tests for real. 5. I think American doctors, their healthcare institutions and their medical schools have a serious problem with the medical ethics if so many doctors are that criminally minded.
camhart 4y ago
Why can't healthcare be fixed? I'm self employed, pay a crap ton of money for "good" insurance, and it's horrible. It's very difficult to find good doctors in network. Everything gets rejected from insurance and the Dr has to appeal it multiple times in order to sometimes get them to budge. It's absolutely broken, and even more so for those on individual and family plans (ie not through an employer). Last year I was with United Healthcare, this year Blue Cross blue shield. Both are horrible. Both are massive companies.
- kofejnik 4y ago
  It is working as intended. All parts of the system co-evolved to extract maximum value from you.
- eapressoandcats 4y ago
  In the US at least the underlying problem is that we pay more for basically every medical procedure, drug, and device, so you end up paying more to get less. Largely this is due to having engineered a shortage of doctors combined with no negotiation on drug and medical device prices.
- ratg13 4y ago
  Once you get rich or in politics, healthcare is no longer a problem, so you don’t see it. Even this thread is full of Americans trying to tell other Americans that the US system is “better” than Europe
  - camhart 4y ago
    Europe's healthcare isn't perfect like many Americans make it out to be. It has its own list of cons. Although it is very nice when you go to a Dr there and talking about money isn't even a thing. My wife is German. There are Dr's that refuse to work with insurance altogether. There are procedures not covered at all. The employer pays for half the insurance, the state (aka taxes... so you) pay for the other half. Self employed people who failed to pay their "half" can still end up with life crushing bills (personal experience in the family). Not sure what happens if unemployed (I assume the State does step in there to cover it 100%?).
snozolli 4y ago
“Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.” Something about "do no harm" comes to mind.
- knodi123 4y ago
  was it the hypocritic oath, "second, do no harm"?
daviddever23box 4y ago
There is a curious irony regarding retirement funds that invest in health insurance companies: if one is healthy and pays into the system, the insurers will reap ample profits, and one's retirement plan will reap the benefits. Get sick, and one may never make it to retirement....
catchnear4321 4y ago
Any “health insurance” in the States do otherwise?
sheeeep86 4y ago
You can attack the management, but also you should look at the people doing the action. If medical doctors participate in such a scheme I feel that the medical schools should strongly consider revocation of degrees as an option. Clearly these doctors are violating their oaths.
throwawayce 4y ago
I work for Cigna, and recently went through cancer treatment. They rejected every scan and treatment until my doctor challenged. My first doctor couldn't figure out how to challenge and it set back my initial treatment. Then last year the CEO did a town hall with a tear jerker clip show about how evicore is helping cancer patients. But evicore is the part of Cigna that kept rejecting my treatment. It was incredibly insulting, and I've been ashamed to work there since.
- nine_zeros 4y ago
  Brutal. Once you get the treatment and feel better, please share it with your local news stations. This is the kind of story that should take the company out of business.
  - borissk 4y ago
    The local news station probably receives a big part of it's budget and profits from medical ads. It won't run any material that can threaten it's main income.
- throw737away 4y ago
  That is sick. I'm sorry. I remember that town hall. I know people at evicore. Some of them even seem to take pleasure in the fact that patients and doctors call them EvilCore. They're very convinced that evicore delivers superior outcome at lower cost. I quit Cigna late last year. Couldn't take the place anymore.
  - olliej 4y ago
    > They're very convinced that evicore delivers superior outcome at lower cost. A superior outcome by what measure? Non-treatment with a cheaper life insurance payout than cost of treatment is "superior". Treatment with a worse long term outcome that is cheaper overall is "superior".
    - throw737away 4y ago
diebeforei485 4y ago
Obama gave the insurers (who are big donors/lobbyists) way too much power.
binarymax 4y ago
The fictional story “The Rainmaker” is about a fictional insurance company with a secret internal policy to deny all claims on first submission, and only fulfill some claims on appeal. It was meant to be fiction, but I suppose it’s not. This whole company should go down for fraud.
- theGnuMe 4y ago
  Yeah that's basically a true story, also before the ACA there were plans that would deny your insurance claiming that you lied during the underwriting process if you used the insurance. It was big news at the time and lots of state action against those plans. I think Cigna needs to be sued class action style for denials. I think it would probably work in the case where Cigna is operating as the claims administrator which is where your company self-insures (so they pay the claims) but Cigna just deals with the paperwork. I would not be surprised if Cigna advertises its services to large companies as "cost effective" etc...
  - d1str0 4y ago
    I’m not familiar with class-actions, but I assume they would not work well for a class pool that has an extremely wide ranging list of claim value, and background evidence/ailments.
rgblambda 4y ago
So the law says a Doctor must review the claim. An algorithm does what effectively is a pre-review of each claim and the Doctor just clicks accept without even checking a single sample in each batch of pre-reviewed claims. This cannot possibly be legal.
switch007 4y ago
> “Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.” This is more or less how the UK government handles benefits (welfare) applications. It’s cruel and demeaning and damaging to health in many many cases.
dcow 4y ago
What would be the problem with requiring all healthcare to be non-for-profit? You can still have it privatized, but you can’t ever be in a situation where you’re trying to maximize profits. Someone poke holes in the idea…
- AnthonyMouse 4y ago
  The incentive to maximize profits (i.e. minimize costs and maximize number of customers) is the benefit of a privatized market. The profit-minimizing mechanism is supposed to be competition, because then people switch away from plans that have a poor balance between price and rejecting claims. But because most plans are tied to employers, that part doesn't work. If you had a non-profit with no competition it would be little different than the government, i.e. susceptible to regulatory capture and with poor incentives to constrain bureaucratic inefficiency. Non-profits in a competitive market would be better, but so would for-profit insurers in a competitive market. The problem isn't that somebody is making money -- a service is being provided and somebody is getting paid one way or another -- the problem is it's too hard to switch so bad providers proliferate.
  - dcow 4y ago
    I understand what you’re saying but I don't think it’s so simple when you involve human lives. When you have shareholders and a board demanding profits, fucked up things happen like you don’t get the new MRI machine because it’s bad for the bottom line. Or you pass on the state of the art surgical robot because it won’t pay for itself quick enough. Both examples would increase outcomes for patients but don't happen because the board chooses profits. I am from a family of primarily doctors for multiple generations so I have 2nd hand experience with this crap. I think as a society it would be totally reasonable for us to say “we don't want profiteering in healthcare”. If you set out to take care of people then your business may only cover costs, which includes reinvesting into the business and your employees. You can never be in a situation where you’re weighing profits against patient care because the conflict of interests is considered unacceptable. I would love to see more people advocate for that stance.
    - 4y ago
moogly 4y ago
The title is missing "of Dollars". Right now one might mistakenly think it implies "of People".
honkycat 4y ago
But hey: at least they owned the libs this month by passing a disgusting anti-trans bill. That is what is important right? Not stopping the massive corruption from every mega-corporation in every sector that is making our earth uninhabitable and our lives miserable. Lets hyper focus on people's sexuality.
- vobox 4y ago
  [flagged]
  - eggsmediumrare 4y ago
    Permanent measures should be taken very, very seriously and there should be thorough investigation into long term outcomes. This is not at all what the Republicans care about. They aren't doing this because they care about the health of vulnerable kids. They just don't like trans people.
    - vobox 4y ago
      No "thorough investigation" is being done in the US. European countries have halted this treatment because of a paucity of data and evidence of poor outcomes. But the US just ploughs ahead regardless - perhaps a symptom of its for-profit health care system, each transed kid is worth many $$$ in lifetime treatment. So for legislatures to ban this, is the only reasonable path forward to save kids from this type of medical abuse.
      - eggsmediumrare 4y ago
        That could all very well be true, but in that case it feels like most Republican lawmakers have arrived at the right conclusion by accident.
elromulous 4y ago
I interpreted "saves millions" as "saves millions of lives". I couldn't have been more wrong.
SkeuomorphicBee 4y ago
The USA medical insurance system is missing a "stick" for such bogus rejections. Unduly denying a claim should result in a fine big enough to be felt in the company balance sheet, that is the only way to change companies' behaviours. , missing some kind of harsh
- avidiax 4y ago
  What if we just don't have a stick. The government or a company they hire is the party that reviews claims. The insurance contacts must have standardized terms and conditions. This probably wouldn't even really hurt the insurance companies. They would not need to compete with each other by denying claims on the backend to provide lower prices on the frontend. The current system is a race to the bottom.
  - thallium205 4y ago
    The terms and conditions (usual and customary) are already there. People just don’t know what they are.
Logans_Run 4y ago
Free Market, Self-Regulation, Share-Holder Value. My Friends, The Revolution is near. There comes a time when the common man can no longer stand idly by and watch as their brothers and sisters (and themselves) continue to be screwed over. There are many amongst you that fear speaking out in the vain hope that some day that they will get their share of 'the Good Life'. I regret to inform you that if it was going to happen, it would have happened to you by now. Don't remain silent nor inactive in fear of rocking the boat, the 'they' are mocking you and holding out a carrot on a stick while you blindly plod on in the hope of 'some day'. Do what you can, when you can. Even the smallest ant can overcome an elephant. Do not be discouraged nor disheartened if you feel there is nothing you can do. That is what the 'they' count on. Enough of this Shit!
- whatthesmack 4y ago
  There's no free market for healthcare in the US. What you mean is crony capitalism and corruption. If there was a free market for healthcare and health insurance in the US, it wouldn't be so expensive.
duxup 4y ago
I was on a jury on a civil case that involved medical claims. The insurance company doctor seemed like a doctor who sort of plodded his way through jobs and eventually just found a place where he could be a doctor and just reject insurance claims. Dude didn't seem to actually know all the medical claims involved in the case, seemed confused about what kind of care was done ... just not at all on the ball. When we deliberated and reviewed the evidence absolutely nobody on the jury had any faith in the insurance company's doctor and we disregarded his testimony entirely. I honestly felt like there should be some consequences for someone acting as a "doctor" testifying in a court case and having very little clue what was going on, but choosing to testify.
- kwhitefoot 4y ago
  > there should be some consequences for someone acting as a "doctor" testifying in a court case and having very little clue what was going on, but choosing to testify. It will make no difference. It is the people higher up and the investors in the company who are responsible. The doctors in question don't behave as they do just because they want to, they do it because that is what the company that employs them demands.
  - duxup 4y ago
    I'd like to see the doctor be at least at risk of losing his license. It's a serious profession and should be held to standards.
    - nine_zeros 4y ago
      I'd like to see the doctor's license suspended and all exec pay to be held until investigation of malpractice is complete.
    - hayst4ck 4y ago
      If you reach out to the medical licensing board and communicated that situation it's not implausible that there would be consequences. Here is what it is for California: https://www.mbc.ca.gov/Consumers/File-a-Complaint/complaint-process.aspx https://www.mbc.ca.gov/Consumers/File-a-Complaint/complaint-... https://www.mbc.ca.gov/FAQs/?cat=Complaint&topic=Complaint:%20Investigations https://www.mbc.ca.gov/FAQs/?cat=Complaint&topic=Complaint:%... What kinds of complaints warrant a formal investigation? In general, any complaint that would warrant disciplinary action if substantiated (e.g., sexual misconduct, gross negligence and/or incompetence, etc.) is referred for investigation. Other kinds of complaints may also require a formal investigation. These include physician impairment, unprofessional conduct and unlicensed practice issues.
Osiris 4y ago
My insurance is denying mental health care for my teenager who has Autism. They also rejected prescriptions given by my doctor for reasons that the doctor would already have taken into account. Both rejections came with a note to “not stop getting care”. In my opinion, insurance companies should not be able to override a doctor.
32kfjh23 4y ago
vD is stored in the bones? Author needs to get facts straight as that’s the first thing you read. Is ProPublica quality going down?
charles_f 4y ago
I somewhat get why you'd build such a system when on the other side you've got pharma and labs pulling for useless medication and tests through doctor presents and "seminars". What's beyond me* is how health insurances get to be the deciding entity when there's such a blatant conflict of interest in the matter, which gets abused as it is here demonstrated. If you get a home insurance claim, at least here in Canada the insurance company has to use an external adjuster. Even though it's not perfect, it seems a widely better solution to handling claims. * it's not beyond me, it's probably just the result of lobbying
pcurve 4y ago
I’ve been working in the industry for 20 years. All companies do this. I don’t think this is even the worst example of rule driven coverage review
smsm42 4y ago
Imagine spending years studying medicine and ending up doing this.
thallium205 4y ago
Insurance companies deny medical necessity claims because the procedure and diagnosis code combinations don't align with what is pre-determined to be medically necessary. One of the big reasons why this happens that nobody ever talks about is because the doctors office does not code the claim correctly and it gets denied. The patient is pissed and blames the insurance company, the doctor is pissed and blames the insurance company, but in reality its the biller/coder in the back office who screwed it up.
- borissk 4y ago
  All right, US insurance companies deny millions of valid claims not because of greed, but because "the doctors office does not code the claim correctly". It's just an unforeseen side effect that said insurance companies end up with billions of annual profits and patients sometime die... Your post remains me of how Russians often react on their forums to posts regarding the corruption in Russia. There are undeniable proofs of how corrupted Putin regime is. All ministers, members of president administration, local administration, judges, generals, etc. end up owning multi-million properties both in Russia and Europe/USA, but many regular people find the stupidest excuses of how the system is fair and just, but "the doctors office does not code the claim correctly".
  - thallium205 4y ago
    I’ve worked in healthcare revenue cycle management for over a decade. If you don’t accurately tell the insurance company what you’re doing and why you’re getting denied. Doesn’t matter if it’s health, auto, home, etc. There are thousands of codes, millions of combinations, and all being mostly hand coded by minimum wage workers. There are constant fuck ups most of which don’t require anyone but a computer to review to know it’s wrong. But okay cool conspiracy.
    - borissk 4y ago
      Even if we assume you're right, the way that the system is setup and the fact that there are constant fuck ups, but no effort to fix them are not accidents. Yes, there are conspiracies out there (surprise, most people are not angels) and the US health system is definitely one. Check out the insurance companies profits. Those are directly linked to denied customer claims. Claims are not denied en-mass, by accident obviously - unless you're a complete fool.
jc_811 4y ago
Wow. This is almost the exact plot of The Rainmaker by John Grisham[1] that came out in 1995: “Rudy uncovers a scheme by Great Benefit to deny every insurance claim submitted, regardless of validity. Great Benefit was playing the odds that the insured would not consult an attorney. A former employee of Great Benefit testifies that the scheme generated an extra $40 million in revenue for the company.” [1] https://en.m.wikipedia.org/wiki/The_Rainmaker_(novel) https://en.m.wikipedia.org/wiki/The_Rainmaker_(novel)
hughw 4y ago
Where are the professional bodies for physicians in all this? These doctors seem to be using their medical credentials to get paid for fake work.
more_corn 4y ago
This country sucks. They’re literally killing us for increased profit margins. It is sickening. Perfectly legal, will not fix.
PuppyTailWags 4y ago
There's a viral case going around where a doctor whose lost his license due to replacing a hip backwards is now making his living denying insurance claims. It's not just that claims are being denied unread, but when they are read, it's not exactly the medical cream of the crop doing the work.
xtracto 4y ago
I keep and keep saying that health insurance is a scam. Paying to a company for a service when their explicit objective is to AVOID providing that service or to minimize the money they spend is plain wrong. Even medical professionals are angry at the system (check r/medicine) . We are two parties in a transaction being screwed by a third party which only value is to extract profit as an intermediary... even a lending setup (instead of a insurance) would be better. Or imho better yet, socialized medicine.
- Jensson 4y ago
  Problem is that neither the patients nor the doctors choose health insurance so they both get screwed over. Your company CFO chooses your health insurance and the hospital managers chooses what health insurances to collaborate with.
- engineer_22 4y ago
  Government intervention is clearly necessary, but having government take over the industry is obviously the most drastic step we can propose.
sublinear 4y ago
Imagine how much more ruthless it would be if it was run by "AI"
amai 4y ago
Why should a blood test for Vitamin D cost $350? In Germany blood test for vitamine D are also not covered by the insurance. But they cost 16€. I believe the algorithm might be right in the example given in the text. The costs for such a simple test are excessive and the case should be rejected. It sounds to me what is described here is simply an algorithm for fraud detection, which many companies use.
ThePowerOfFuet 4y ago
>As a physician, van Terheyden said, he’s dumbfounded by the company’s policies. >“It’s not good medicine. It’s not caring for patients. You end up asking yourself: Why would they do this if their ultimate goal is to care for the patient?” he said. Because their ultimate goal is to make money, as with the entire health "care" system in the US. Yet another reason blue card trumps green card.
mmranger 4y ago
I worked customer service for years with a cell carrier in the US. It was tiring hearing everyone's problems with their luxury devices(at that time). I left and got a job at Aetna customer service 6 weeks of training and I walked in the first week on the job. After getting off a call with an elderly gentleman trying to figure out why we weren't paying for his wife's medical care. And all I could say was the plan you have well not cover that because you didn't jump through some ridiculous hoop. A hip that as a young adult I would have struggled to complete let alone a very old person who doesn't understand what is required and there is no one to help him.
bithead 4y ago
I am a T1 diabetic, and worked for UnitedHealth Group. During that time they decided to stop paying for my insulin with no substitute for it, in spite of several cheaper substitutes existing. Thank god for Canada mail pharmacies. No amount of oversight of health insurance is too much. Health insurance companies should be forbidden from owning or otherwise influencing any health care provider (sounds like a RICO thing now that I type it out). Mandatory prison time for CEO's and any other corporate officers if they knew about the offense and failed to notify authorities. Also fines base on gross revenues, at least 10%. Make shareholders pay as well. Also mandatory incarceration of corporate officers while investigations take place.
consultSKI 4y ago
#sad
norswap 4y ago
I thought the headline was about saving millions of lifes and got really confused for a hot minute.
thewileyone 4y ago
Insurance companies are scum of the earth. A relative, who's a Prudential agent, bragged that Prudential had billions in their war-chest. I replied that's because ya'll don't payout any claims.

564 points by metadat 4y ago

Somebody should make an AI service that automatically files appeals. I suspect that the cost of the appeals process would negate the savings they make from auto-denying claims.

stathibus 4y ago

This reminds me of the US patent approval system. There are too many claims to properly vet them all, so just "click and submit" and only put effort into the ones that come back to complain. (Except the PTO is biased toward approval and not rejection, of course.)

AnthonyMouse 4y ago
Not exactly. The US PTO rejects a large proportion of patent claims. It can be quite expensive / time consuming to get a US patent as an individual inventor. But you can appeal the rejections, and large corporations and patent trolls have staff attorneys who do that all day long, so then tons of garbage patents get approved too.

woohoo7676 4y ago

This has been happening to me for the past several months. 1. Cigna will not tell you for any reason, why the claim is denied 2. Reps will not help at all other than "Oh I see the issue, will reprocess" which often just results in another denial 3. The issue that a helpful rep finally disclosed: Cigna's own claim form for providers has a box that is overloaded for procedure code and equipment code; apparently the CPT code for therapy is the same as the equipment code for injections. So one claim processor decided that the claim was for injections and denied it. Then every subsequent claim has been denied under the same reason. 4. At this point the only option for me is for my provider to appeal every single claim (which takes months), as this is the only way to get someone to actually read the claim and make an intelligent decision. An absolute nightmare :(

kurikuri 4y ago
I always wonder if small claims court could be somewhat viable. In the instances where I’ve fought and gotten approval, I’ve spent my own time, my own money, and had my health deteriorate. Ideally, I’d like to be compensated for the time I’ve spent defending myself to this company, and I’d like some form of remuneration (somewhat for retribution, somewhat as a negative incentive to the company) for my now diminished health…
- Kye 4y ago
  There needs to be something like the CFPB for health care. I couldn't get an actual human to acknowledge me when dealing with PNC when they ate up my bank, but one CFPB complaint got them to do exactly what I asked. That way you never get to the point of burning time, money, and health because they're afraid of action from the agency.
  - lotsofpulp 4y ago
    It would be the state’s insurance regulator, although do not know if they are as effective as CFPB. Financial issues tend to be much less complicated than health issues, and usually just a result of understaffing and underinvesting in customer service.
  - woohoo7676 4y ago
    Great idea - agreed we need an agency to go to that has some teeth, as the insurance co's will never be afraid of individuals.
- firstlink 4y ago
  If you have health insurance from your employer, it's probably covered under ERISA. This is federal, so no help from your state insurance agency and no small claims, and I have found that there are few lawyers who will touch it even in a large city.
indymike 4y ago
> 1. Cigna will not tell you for any reason, why the claim is denied Of course not. Fight fire with fire. Get care providers to sign a letter to Cigna saying the procedure is medically necessary Going through the process will not work and will go slow. But putting them on notice by having licensed, local care providers say something is medically necessary and urgent will work almost 100% of the time.

blakesterz 4y ago

“We thought it might fall into a legal gray zone,” said the former Cigna official, who helped conceive the program. “We sent the idea to legal, and they sent it back saying it was OK.” Reading this article is just maddening. I've been dealing with different insurers for the past 7 years or so, and it's my experience they must all do something similar. Anyone with any kind of serious health condition is regularly driven CRAZY dealing with insurance. It's just an insane and broken system.

kurthr 4y ago
Wife is a nurse. Required surgery for lifesaving/severe disability (inherited congenital, killed her father). Insurance was Aetna and Hospital Self Insured. Surgery recommended by world class surgeon she worked with. Finally pre-approved on 3rd appeal after 8 months and 150pages of documentation of every piece of every single communication (who, when, response, expected next contact) only weeks before surgery scheduled >6 months before. First rejection was automatic, second was revealed to be a dermatologist, third was a gynecologist. (They really hated that we figured out who the person was, their specialty, the state they worked in, and pending disciplinary actions). Standard answer is we can't tell you why you were rejected (code only) because the criteria are from a third party and their review document is proprietary. When you find an online leaked document with the same code it says "unnecessary cosmetic surgery". Wrong contact numbers are provided, people go on vacation and do not respond for weeks, "that person doesn't work here". If you're not a professional in the field with time on your hands and a detail oriented A-hole, you will be denied anything expensive that isn't considered immediately lifesaving at a trauma ICU recommended by the attending. After pre-approved surgery with excessive blood loss and an extra 12 hours in recovery... Overcharge/All-claims-denied. Multiple appeals until involving Hospital CFO who agrees to split the extra (self-insured) cost of the insurer and get the final insurance reimbursement check... it is $3k less than promised (hospital paid the correct amount). Surgeon was going to start charging late fees and interest or send it to collection after 4 months. Is it worth fighting any more? No.
- anigbrowl 4y ago
  Standard answer is we can't tell you why you were rejected How did you find out about the automatic rejection/identity of the reviewers?

dafelst 4y ago

Privatized health care as a person's sole option for care is an absolute dystopian nightmare. Any system that requires balancing human suffering against profitability is inevitably going to optimize for profitability. The fact that this is even a thing is mind boggling.

xwdv 4y ago
Public health care can be similarly dystopian in other ways: Very long wait times due to limited resources, subpar medical care, limited prescription options and drugs, beauracracy. No matter what society you live, the advice is the same: try not to get sick.
- PicassoCTs 4y ago
  Ah, yes, have a privatized public sector, use the gained funds to lobby in other countries, pushing a ideology that destroys public sector/services, use the result of ones own actions to push the conversion to more privatized public sector. The ultimate glider gun ideology.
- weaksauce 4y ago
  > Very long wait times due to limited resources, subpar medical care, limited prescription options and drugs, beauracracy. those are all there because the people that created the system did not think paying for it was good enough. it doesn't have to be that way. and even with wait times being long you still eventually get it. in the privatized system if you are poor and have bad health care you don't get it at all.
- harshalizee 4y ago
  I moved from a third world country with both socialized and private healthcare, to the United States. I pay vastly more for worse healthcare than anywhere I've lived. The fact that you, your doctor can agree that a certain procedure is required, only to be denied by a third party with no medical qualification is absolutely dystopian.
  - 4y ago

lotsofpulp 4y ago

And still Cigna’s profit margins are low single digit percentages. https://www.macrotrends.net/stocks/charts/CI/cigna-group/profit-margins https://www.macrotrends.net/stocks/charts/CI/cigna-group/pro... Wonder what premiums and out of pocket maximums would have to be if there were fewer denials.

OrvalWintermute 4y ago
If they are paying out huge sums to their c-suite, giving them stock left and right, and enriching the company through stock schemes or dividend payouts, unjustly, perhaps their compensation shouldn't be so rich? https://www.statnews.com/2022/05/12/health-insurance-ceos-raked-in-record-pay-during-covid/ https://www.statnews.com/2022/05/12/health-insurance-ceos-ra...
- candiddevmike 4y ago
  C-suite, board members, a bunch of "foundations", probably some for-profit contracting services for IT and accounting (also managed by the c-suite, probably). Unraveling health insurance admin costs is probably similar to Panama Papers level of financial engineering, especially after the ACA capped profit margins, the companies just turned to malicious compliance.
  - lotsofpulp 4y ago
    If you look at the 10-K for any of the 7 publicly listed health insurers, administrative cost increases are minuscule compared to healthcare expenditures. You can get rid of half the employees and cut everyone’s pay by half, and it won’t make much difference. I think the US’s biggest problem in healthcare is liability. Every entity is spending so many resources on making sure that they do not get blamed in the event there is a lawsuit, because the damages are huge. In countries with taxpayer funded healthcare, this liability issue is much less because you are dealing with the government only and suddenly liability and damage amounts are reduced.
- vkou 4y ago
  I think we can just go a step further and kill their entire toxic business model. After decades of observing how it behaves, it should be pretty clear that it's always going to devolve down to privately-ran death panels.

prophesi 4y ago

I wish I was surprised. Automated decision-making with little to no human oversight is the dream of risky bets (policing, insurance, loans, etc).

hestefisk 4y ago

This is the reason we need universal public healthcare.

luckylion 4y ago
That won't help you there. Germany's public healthcare system denies plenty of things too, and will only pay for treatment when you sue (or know someone who works there). Germany's private healthcare system on the other hand is usually better (I'm sure there are exceptions and some insurance company that sucks).
- hestefisk 4y ago
  You can have good public healthcare without the need of the notion of 'claims'. The Scandinavian healthcare system is a good example (https://en.wikipedia.org/wiki/Healthcare_in_Denmark https://en.wikipedia.org/wiki/Healthcare_in_Denmark).
  - firstlink 4y ago
    > The central government plays a relatively limited role in health care in Denmark. So the exact opposite of what people usually mean when they say they want public healthcare. Words mean something.
    - theossuary 4y ago
      Public healthcare means health care paid for via public funds, nothing more. Many public health care systems aren't entirely centralized, even though they use public funds. For example even the UK's NHS has regions with allocated budgets they manage based on the number of patients they see, which they then spend as they see fit. You're trying to attach your biases and assumptions onto an amorphous phrase, and then pretend others are using it wrong because they don't have the same expectations. That isn't reasonable.
    - hestefisk 4y ago
      I am of Danish origin and stating that the central government has a limited role in healthcare is just downright incorrect. The Ministry of Health (Sundhedsstyrelsen) sets the budget, determines national practices, manages the public health insurance scheme, and manages the list of approved medicines. Yes, execution of healthcare is with the regions, but there has been a significant increase in centralisation of healthcare since the “amter” were disbanded.

netmonk 4y ago

[dead]

loeg 4y ago

> His claim was just one of roughly 60,000 that Dopke denied in a single month last year 60,000 / 20 workdays in a month / 8 hours in a workday => this guy rejected about 375 claims per hour, on average. Over six claims a minute. He spent less than 10 seconds on each claim, for a full month of work time.

Centigonal 4y ago
Less than 10s/claim is actually an upper bound, since chances are there's meetings, coffee breaks, and other overhead.
prepend 4y ago
I mean supposedly the doctor also approved some so their review rate is even higher.
SapporoChris 4y ago
"A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments." "Cigna said its review system was created to “accelerate payment of claims for certain routine screenings,” This sounds like simple automation with an error rate that is acceptable by Cigna. Of course it's not acceptable to anyone wrongfully denied a claim. Now that's an issue I don't see in the article. How many claims were wrongfully denied? I can't get worked up about the situation when critical information is missing.
- ahi 4y ago
  They are not legally allowed to automate this. These cases MUST be reviewed by qualified medical personnel.
- magicalist 4y ago
  > Now that's an issue I don't see in the article. How many claims were wrongfully denied? Well gee, to actually estimate that you'd need a medical expert to review the claims.
- IG_Semmelweiss 4y ago

courseofaction 4y ago

Jail the executives.

RainbowFriends 4y ago
Revoke the medical licenses of the doctors who rubber stamp the denials.
- dragonwriter 4y ago
  In addition, states (as the pirnary regulators of insurance) should adopt a rule that if an insurer has a policy which directs, incentivizes, or which managenment knows or should reasonably know results in denials without good faith review, the state then has a cause of action against the insurer for damages of equal to triple the amount originally denied without appropriate review (whether or not later paid), and will, if necessary, pierce the corporate veil to recover it and, separately, each medical reviewer who is found to have denied a claim without good faith review shall be fined an amount equal to the value of claims so denied and prohibited (regardless of whether their medical license may later be restored) from being responsible for medical review of insurance claims in the state in the future.

ncallaway 4y ago

I genuinely think every health insurance denial should have to come from a named doctor at the health insurance company who is personally and professionally liable for the health outcomes from a denial. Deny someone life-saving care without a sound medical reason? That’s a malpractice lawsuit and a potential loss of their medical license.

theGnuMe 4y ago
There's some doc on twitter who was denied by insurance and he filed a board complaint against the insurance doc claiming malpractice. I think he won.
- d1str0 4y ago
  Know any more details? This seems rather promising.
  - theGnuMe 4y ago
    https://twitter.com/generalorthomd/status/1632074816378507264 https://twitter.com/generalorthomd/status/163207481637850726...
  - IG_Semmelweiss 4y ago
    the claim denier worked for insurance. he had a complaint on file for entering a hip replacement backwards the tweeter thread shows devastating images . the point is that a provider like that, has no business denying coverage. plus apparently he was not board cert and other issues from lapses in licensing
- ncallaway 4y ago
  Yep, basically we should make it much easier to identify the specific doctor that is responsible for the denial (to make them easier to sue personally, and discipline professionally), and we should make the liability for such a denial extremely explicit.
kube-system 4y ago

electrondood 4y ago

For anyone who is against government regulation... this is another perfect example of the kind of perverse financial incentives unregulated capitalism results in. Blanket denial without consideration lowers your costs as an insurance provider, because it acts like a filter on people who care enough to appeal repeatedly.

whatthesmack 4y ago
This is not unregulated capitalism. This is crony capitalism or corruption. It is government regulation that allows a monopoly of large corporations to remain the powerful health insurance companies they are, and ObamaCare gave them even more power. If this was a free, unregulated market, healthcare in the US would be cheaper.

deleted 4y ago

[deleted]

mdmglr 4y ago

Maybe to speed things up patients can opt to have ChatGPT read the claim and make a decision. /s

readme 4y ago
it would probably benefit patients
- Ekaros 4y ago
  AIs are wrong at least some of the time... That means they will approve some claims. Not deny all of them.

pontifier 4y ago

Automatic rejection is a tactic used by all sorts of con artists. If they say no and you never come back then they don't have to worry about you anymore.

lostmsu 4y ago

I am surprised commenters here did not read into the nuance: > A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity. Before grabbing the pitchforks, it is important to be sure if their policy is reasonable or not. Whose fault is it if doctors ask clients to perform expensive tests, because they can't be bothered to actually think and figure out what test would be the most optimal? Now even if the doctors really overprescribe tests, I don't think the client should be responsible. Instead, the insurance should pay, but kick the doctor out of their network.

sidlls 4y ago
I don’t think we should trust the soundness of their algorithm. I’ve worked in the healthcare space before, and the perverse incentives involved should make everyone extremely skeptical of insurance companies’ motivations, procedures, and algorithms.
- lostmsu 4y ago
  From the description it sounded like something trivial. E.g. given the diagnosis, there might be a cheaper known way to get to it. I am a layman, but for instance that could be ordering an MRI when an ultrasound would suffice.
salawat 4y ago
Fuck that. You know what that incentivizes? Not testing at all. You know what that leads to? Bad outcomes. I'm all for selection pressure toward more efficacious, less invasive, less dangerous tests. Writing an insurer a blank check to blanket deny millions of claims without checking or reading up though? Nah. That's profiteering. You want to run that algo in parallel and dift through the claims that would change, individually weeding out the actual false positives? Kosher. Just YOLO'ing it on prod and trottingbit out in front of investors? Hell no.
soared 4y ago
It’s insane to trust an insurance company to make healthcare decisions. I was denied an MRI when I tore my hamstring off the bone, and so my doctor had zero info on what my treatment options should be. I went to physical therapy when I possibly should have had surgery. I’d so much rather 10% of people overpay for unnecessary tests than the other 10% of people be denied potentially necessary care.

vfclists 4y ago

There a few points to be made here: 1. The doctors who signed of on those batches should be sued for medical malpractice and negligence. Where is the AMA on this issue? 2. Why are the tests so expensive? All it requires is to add some chemicals to the blood sample or whatever and see if it changes color or something? $1000 of dollars? 3. Isn't there a trust relationship between Cigna and the doctors who authorize the tests? Does Cigna believe that some of its doctors have a relationship with the testing companies where they receive kickbacks for authorizing the tests? 4. The patients whose tests were signed of in batches must file a class action lawsuits against each doctor separately and Sigma. The doctors and Cigna are colluding in medical fraud. Even if subsequent indepth evaluations indicate that declining a tests was justified they should still be sued as they signed off the tests without actually doing the tests for real. 5. I think American doctors, their healthcare institutions and their medical schools have a serious problem with the medical ethics if so many doctors are that criminally minded.

camhart 4y ago

Why can't healthcare be fixed? I'm self employed, pay a crap ton of money for "good" insurance, and it's horrible. It's very difficult to find good doctors in network. Everything gets rejected from insurance and the Dr has to appeal it multiple times in order to sometimes get them to budge. It's absolutely broken, and even more so for those on individual and family plans (ie not through an employer). Last year I was with United Healthcare, this year Blue Cross blue shield. Both are horrible. Both are massive companies.

kofejnik 4y ago
It is working as intended. All parts of the system co-evolved to extract maximum value from you.
eapressoandcats 4y ago
In the US at least the underlying problem is that we pay more for basically every medical procedure, drug, and device, so you end up paying more to get less. Largely this is due to having engineered a shortage of doctors combined with no negotiation on drug and medical device prices.
ratg13 4y ago
Once you get rich or in politics, healthcare is no longer a problem, so you don’t see it. Even this thread is full of Americans trying to tell other Americans that the US system is “better” than Europe
- camhart 4y ago
  Europe's healthcare isn't perfect like many Americans make it out to be. It has its own list of cons. Although it is very nice when you go to a Dr there and talking about money isn't even a thing. My wife is German. There are Dr's that refuse to work with insurance altogether. There are procedures not covered at all. The employer pays for half the insurance, the state (aka taxes... so you) pay for the other half. Self employed people who failed to pay their "half" can still end up with life crushing bills (personal experience in the family). Not sure what happens if unemployed (I assume the State does step in there to cover it 100%?).

snozolli 4y ago

“Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.” Something about "do no harm" comes to mind.

knodi123 4y ago
was it the hypocritic oath, "second, do no harm"?

daviddever23box 4y ago

There is a curious irony regarding retirement funds that invest in health insurance companies: if one is healthy and pays into the system, the insurers will reap ample profits, and one's retirement plan will reap the benefits. Get sick, and one may never make it to retirement....

catchnear4321 4y ago

Any “health insurance” in the States do otherwise?

sheeeep86 4y ago

You can attack the management, but also you should look at the people doing the action. If medical doctors participate in such a scheme I feel that the medical schools should strongly consider revocation of degrees as an option. Clearly these doctors are violating their oaths.

throwawayce 4y ago

I work for Cigna, and recently went through cancer treatment. They rejected every scan and treatment until my doctor challenged. My first doctor couldn't figure out how to challenge and it set back my initial treatment. Then last year the CEO did a town hall with a tear jerker clip show about how evicore is helping cancer patients. But evicore is the part of Cigna that kept rejecting my treatment. It was incredibly insulting, and I've been ashamed to work there since.

nine_zeros 4y ago
Brutal. Once you get the treatment and feel better, please share it with your local news stations. This is the kind of story that should take the company out of business.
- borissk 4y ago
  The local news station probably receives a big part of it's budget and profits from medical ads. It won't run any material that can threaten it's main income.
throw737away 4y ago
That is sick. I'm sorry. I remember that town hall. I know people at evicore. Some of them even seem to take pleasure in the fact that patients and doctors call them EvilCore. They're very convinced that evicore delivers superior outcome at lower cost. I quit Cigna late last year. Couldn't take the place anymore.
- olliej 4y ago
  > They're very convinced that evicore delivers superior outcome at lower cost. A superior outcome by what measure? Non-treatment with a cheaper life insurance payout than cost of treatment is "superior". Treatment with a worse long term outcome that is cheaper overall is "superior".
  - throw737away 4y ago

diebeforei485 4y ago

Obama gave the insurers (who are big donors/lobbyists) way too much power.

binarymax 4y ago

The fictional story “The Rainmaker” is about a fictional insurance company with a secret internal policy to deny all claims on first submission, and only fulfill some claims on appeal. It was meant to be fiction, but I suppose it’s not. This whole company should go down for fraud.

theGnuMe 4y ago
Yeah that's basically a true story, also before the ACA there were plans that would deny your insurance claiming that you lied during the underwriting process if you used the insurance. It was big news at the time and lots of state action against those plans. I think Cigna needs to be sued class action style for denials. I think it would probably work in the case where Cigna is operating as the claims administrator which is where your company self-insures (so they pay the claims) but Cigna just deals with the paperwork. I would not be surprised if Cigna advertises its services to large companies as "cost effective" etc...
- d1str0 4y ago
  I’m not familiar with class-actions, but I assume they would not work well for a class pool that has an extremely wide ranging list of claim value, and background evidence/ailments.

rgblambda 4y ago

So the law says a Doctor must review the claim. An algorithm does what effectively is a pre-review of each claim and the Doctor just clicks accept without even checking a single sample in each batch of pre-reviewed claims. This cannot possibly be legal.

switch007 4y ago

> “Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.” This is more or less how the UK government handles benefits (welfare) applications. It’s cruel and demeaning and damaging to health in many many cases.

dcow 4y ago

What would be the problem with requiring all healthcare to be non-for-profit? You can still have it privatized, but you can’t ever be in a situation where you’re trying to maximize profits. Someone poke holes in the idea…

AnthonyMouse 4y ago
The incentive to maximize profits (i.e. minimize costs and maximize number of customers) is the benefit of a privatized market. The profit-minimizing mechanism is supposed to be competition, because then people switch away from plans that have a poor balance between price and rejecting claims. But because most plans are tied to employers, that part doesn't work. If you had a non-profit with no competition it would be little different than the government, i.e. susceptible to regulatory capture and with poor incentives to constrain bureaucratic inefficiency. Non-profits in a competitive market would be better, but so would for-profit insurers in a competitive market. The problem isn't that somebody is making money -- a service is being provided and somebody is getting paid one way or another -- the problem is it's too hard to switch so bad providers proliferate.
- dcow 4y ago
  I understand what you’re saying but I don't think it’s so simple when you involve human lives. When you have shareholders and a board demanding profits, fucked up things happen like you don’t get the new MRI machine because it’s bad for the bottom line. Or you pass on the state of the art surgical robot because it won’t pay for itself quick enough. Both examples would increase outcomes for patients but don't happen because the board chooses profits. I am from a family of primarily doctors for multiple generations so I have 2nd hand experience with this crap. I think as a society it would be totally reasonable for us to say “we don't want profiteering in healthcare”. If you set out to take care of people then your business may only cover costs, which includes reinvesting into the business and your employees. You can never be in a situation where you’re weighing profits against patient care because the conflict of interests is considered unacceptable. I would love to see more people advocate for that stance.
  - 4y ago

moogly 4y ago

The title is missing "of Dollars". Right now one might mistakenly think it implies "of People".

honkycat 4y ago

But hey: at least they owned the libs this month by passing a disgusting anti-trans bill. That is what is important right? Not stopping the massive corruption from every mega-corporation in every sector that is making our earth uninhabitable and our lives miserable. Lets hyper focus on people's sexuality.

vobox 4y ago
[flagged]
- eggsmediumrare 4y ago
  Permanent measures should be taken very, very seriously and there should be thorough investigation into long term outcomes. This is not at all what the Republicans care about. They aren't doing this because they care about the health of vulnerable kids. They just don't like trans people.
  - vobox 4y ago
    No "thorough investigation" is being done in the US. European countries have halted this treatment because of a paucity of data and evidence of poor outcomes. But the US just ploughs ahead regardless - perhaps a symptom of its for-profit health care system, each transed kid is worth many $$$ in lifetime treatment. So for legislatures to ban this, is the only reasonable path forward to save kids from this type of medical abuse.
    - eggsmediumrare 4y ago
      That could all very well be true, but in that case it feels like most Republican lawmakers have arrived at the right conclusion by accident.

elromulous 4y ago

I interpreted "saves millions" as "saves millions of lives". I couldn't have been more wrong.

SkeuomorphicBee 4y ago

The USA medical insurance system is missing a "stick" for such bogus rejections. Unduly denying a claim should result in a fine big enough to be felt in the company balance sheet, that is the only way to change companies' behaviours. , missing some kind of harsh

avidiax 4y ago
What if we just don't have a stick. The government or a company they hire is the party that reviews claims. The insurance contacts must have standardized terms and conditions. This probably wouldn't even really hurt the insurance companies. They would not need to compete with each other by denying claims on the backend to provide lower prices on the frontend. The current system is a race to the bottom.
- thallium205 4y ago
  The terms and conditions (usual and customary) are already there. People just don’t know what they are.

Logans_Run 4y ago

Free Market, Self-Regulation, Share-Holder Value. My Friends, The Revolution is near. There comes a time when the common man can no longer stand idly by and watch as their brothers and sisters (and themselves) continue to be screwed over. There are many amongst you that fear speaking out in the vain hope that some day that they will get their share of 'the Good Life'. I regret to inform you that if it was going to happen, it would have happened to you by now. Don't remain silent nor inactive in fear of rocking the boat, the 'they' are mocking you and holding out a carrot on a stick while you blindly plod on in the hope of 'some day'. Do what you can, when you can. Even the smallest ant can overcome an elephant. Do not be discouraged nor disheartened if you feel there is nothing you can do. That is what the 'they' count on. Enough of this Shit!

whatthesmack 4y ago
There's no free market for healthcare in the US. What you mean is crony capitalism and corruption. If there was a free market for healthcare and health insurance in the US, it wouldn't be so expensive.

duxup 4y ago

I was on a jury on a civil case that involved medical claims. The insurance company doctor seemed like a doctor who sort of plodded his way through jobs and eventually just found a place where he could be a doctor and just reject insurance claims. Dude didn't seem to actually know all the medical claims involved in the case, seemed confused about what kind of care was done ... just not at all on the ball. When we deliberated and reviewed the evidence absolutely nobody on the jury had any faith in the insurance company's doctor and we disregarded his testimony entirely. I honestly felt like there should be some consequences for someone acting as a "doctor" testifying in a court case and having very little clue what was going on, but choosing to testify.

kwhitefoot 4y ago
> there should be some consequences for someone acting as a "doctor" testifying in a court case and having very little clue what was going on, but choosing to testify. It will make no difference. It is the people higher up and the investors in the company who are responsible. The doctors in question don't behave as they do just because they want to, they do it because that is what the company that employs them demands.
- duxup 4y ago
  I'd like to see the doctor be at least at risk of losing his license. It's a serious profession and should be held to standards.
  - nine_zeros 4y ago
    I'd like to see the doctor's license suspended and all exec pay to be held until investigation of malpractice is complete.
  - hayst4ck 4y ago
    If you reach out to the medical licensing board and communicated that situation it's not implausible that there would be consequences. Here is what it is for California: https://www.mbc.ca.gov/Consumers/File-a-Complaint/complaint-process.aspx https://www.mbc.ca.gov/Consumers/File-a-Complaint/complaint-... https://www.mbc.ca.gov/FAQs/?cat=Complaint&topic=Complaint:%20Investigations https://www.mbc.ca.gov/FAQs/?cat=Complaint&topic=Complaint:%... What kinds of complaints warrant a formal investigation? In general, any complaint that would warrant disciplinary action if substantiated (e.g., sexual misconduct, gross negligence and/or incompetence, etc.) is referred for investigation. Other kinds of complaints may also require a formal investigation. These include physician impairment, unprofessional conduct and unlicensed practice issues.

Osiris 4y ago

My insurance is denying mental health care for my teenager who has Autism. They also rejected prescriptions given by my doctor for reasons that the doctor would already have taken into account. Both rejections came with a note to “not stop getting care”. In my opinion, insurance companies should not be able to override a doctor.

32kfjh23 4y ago

vD is stored in the bones? Author needs to get facts straight as that’s the first thing you read. Is ProPublica quality going down?

charles_f 4y ago

I somewhat get why you'd build such a system when on the other side you've got pharma and labs pulling for useless medication and tests through doctor presents and "seminars". What's beyond me* is how health insurances get to be the deciding entity when there's such a blatant conflict of interest in the matter, which gets abused as it is here demonstrated. If you get a home insurance claim, at least here in Canada the insurance company has to use an external adjuster. Even though it's not perfect, it seems a widely better solution to handling claims. * it's not beyond me, it's probably just the result of lobbying

pcurve 4y ago

I’ve been working in the industry for 20 years. All companies do this. I don’t think this is even the worst example of rule driven coverage review

smsm42 4y ago

Imagine spending years studying medicine and ending up doing this.

thallium205 4y ago

Insurance companies deny medical necessity claims because the procedure and diagnosis code combinations don't align with what is pre-determined to be medically necessary. One of the big reasons why this happens that nobody ever talks about is because the doctors office does not code the claim correctly and it gets denied. The patient is pissed and blames the insurance company, the doctor is pissed and blames the insurance company, but in reality its the biller/coder in the back office who screwed it up.

borissk 4y ago
All right, US insurance companies deny millions of valid claims not because of greed, but because "the doctors office does not code the claim correctly". It's just an unforeseen side effect that said insurance companies end up with billions of annual profits and patients sometime die... Your post remains me of how Russians often react on their forums to posts regarding the corruption in Russia. There are undeniable proofs of how corrupted Putin regime is. All ministers, members of president administration, local administration, judges, generals, etc. end up owning multi-million properties both in Russia and Europe/USA, but many regular people find the stupidest excuses of how the system is fair and just, but "the doctors office does not code the claim correctly".
- thallium205 4y ago
  I’ve worked in healthcare revenue cycle management for over a decade. If you don’t accurately tell the insurance company what you’re doing and why you’re getting denied. Doesn’t matter if it’s health, auto, home, etc. There are thousands of codes, millions of combinations, and all being mostly hand coded by minimum wage workers. There are constant fuck ups most of which don’t require anyone but a computer to review to know it’s wrong. But okay cool conspiracy.
  - borissk 4y ago
    Even if we assume you're right, the way that the system is setup and the fact that there are constant fuck ups, but no effort to fix them are not accidents. Yes, there are conspiracies out there (surprise, most people are not angels) and the US health system is definitely one. Check out the insurance companies profits. Those are directly linked to denied customer claims. Claims are not denied en-mass, by accident obviously - unless you're a complete fool.

jc_811 4y ago

Wow. This is almost the exact plot of The Rainmaker by John Grisham[1] that came out in 1995: “Rudy uncovers a scheme by Great Benefit to deny every insurance claim submitted, regardless of validity. Great Benefit was playing the odds that the insured would not consult an attorney. A former employee of Great Benefit testifies that the scheme generated an extra $40 million in revenue for the company.” [1] https://en.m.wikipedia.org/wiki/The_Rainmaker_(novel) https://en.m.wikipedia.org/wiki/The_Rainmaker_(novel)

hughw 4y ago

Where are the professional bodies for physicians in all this? These doctors seem to be using their medical credentials to get paid for fake work.

more_corn 4y ago

This country sucks. They’re literally killing us for increased profit margins. It is sickening. Perfectly legal, will not fix.

PuppyTailWags 4y ago

There's a viral case going around where a doctor whose lost his license due to replacing a hip backwards is now making his living denying insurance claims. It's not just that claims are being denied unread, but when they are read, it's not exactly the medical cream of the crop doing the work.

xtracto 4y ago

I keep and keep saying that health insurance is a scam. Paying to a company for a service when their explicit objective is to AVOID providing that service or to minimize the money they spend is plain wrong. Even medical professionals are angry at the system (check r/medicine) . We are two parties in a transaction being screwed by a third party which only value is to extract profit as an intermediary... even a lending setup (instead of a insurance) would be better. Or imho better yet, socialized medicine.

Jensson 4y ago
Problem is that neither the patients nor the doctors choose health insurance so they both get screwed over. Your company CFO chooses your health insurance and the hospital managers chooses what health insurances to collaborate with.
engineer_22 4y ago
Government intervention is clearly necessary, but having government take over the industry is obviously the most drastic step we can propose.

sublinear 4y ago

Imagine how much more ruthless it would be if it was run by "AI"

amai 4y ago

Why should a blood test for Vitamin D cost $350? In Germany blood test for vitamine D are also not covered by the insurance. But they cost 16€. I believe the algorithm might be right in the example given in the text. The costs for such a simple test are excessive and the case should be rejected. It sounds to me what is described here is simply an algorithm for fraud detection, which many companies use.

ThePowerOfFuet 4y ago

>As a physician, van Terheyden said, he’s dumbfounded by the company’s policies. >“It’s not good medicine. It’s not caring for patients. You end up asking yourself: Why would they do this if their ultimate goal is to care for the patient?” he said. Because their ultimate goal is to make money, as with the entire health "care" system in the US. Yet another reason blue card trumps green card.

mmranger 4y ago

I worked customer service for years with a cell carrier in the US. It was tiring hearing everyone's problems with their luxury devices(at that time). I left and got a job at Aetna customer service 6 weeks of training and I walked in the first week on the job. After getting off a call with an elderly gentleman trying to figure out why we weren't paying for his wife's medical care. And all I could say was the plan you have well not cover that because you didn't jump through some ridiculous hoop. A hip that as a young adult I would have struggled to complete let alone a very old person who doesn't understand what is required and there is no one to help him.

bithead 4y ago

I am a T1 diabetic, and worked for UnitedHealth Group. During that time they decided to stop paying for my insulin with no substitute for it, in spite of several cheaper substitutes existing. Thank god for Canada mail pharmacies. No amount of oversight of health insurance is too much. Health insurance companies should be forbidden from owning or otherwise influencing any health care provider (sounds like a RICO thing now that I type it out). Mandatory prison time for CEO's and any other corporate officers if they knew about the offense and failed to notify authorities. Also fines base on gross revenues, at least 10%. Make shareholders pay as well. Also mandatory incarceration of corporate officers while investigations take place.

consultSKI 4y ago

#sad

norswap 4y ago

I thought the headline was about saving millions of lifes and got really confused for a hot minute.

thewileyone 4y ago

Insurance companies are scum of the earth. A relative, who's a Prudential agent, bragged that Prudential had billions in their war-chest. I replied that's because ya'll don't payout any claims.