May 20, 2022 | By Toni Elhoms, CCS, CPC, CPMA, CRC
I know I am not the only one who is completely appalled by the recent bombshell story on Cigna’s shady claims adjudication practices. ProPublica recently published a scathing article that pulls back the curtain on “PXDX” – a cost-containment strategy deployed by Cigna well over a decade ago. According to internal documents and former physician employees of Cigna, the health insurer used an algorithm to systematically deny health insurance claims in massive quantities.
To put things into perspective – in just two months, Cigna physicians denied over 300,000 medical claims for payment. This, in effect, means that Cigna physicians spent 1.2 seconds (on average) “reviewing” and denying each claim. According to a former Cigna physician, “we literally click and submit – it takes all of 10 seconds to do 50 denials at a time.” This disturbing admission further demonstrates Cigna’s (and MANY other insurers) strong commitment to place profits over patients.
Each state has an Office of Insurance Regulation (OIR) that is tasked with licensing and regulating insurance companies operating within each state. The OIR regulates health insurance companies’ policies, rates, market conduct, claims, solvency, administrative supervision, business practices, etc. Before a health insurance company can legally deny a claim for medical necessity reasons, state insurance laws and regulations require doctors to review each claim and make independent and “fair” objective determinations. These “physician-led” coverage determinations are purportedly based on review of patient medical records, recognized coverage policies, evidence-based medicine, and the reviewing physician’s expertise in medicine. When Cigna was questioned about PXDX, they responded, “We thought it might fall into a legal gray zone. We sent the idea to legal, and they sent it back saying it was OK.” Which begs the question – how is Cigna getting away with all of this?
This news comes on the heels of Cigna’s announcement that they fully intend to proceed with their modifier 25 policy effective May 25, 2023! It sure makes you wonder if Cigna reviewers will be employing similar tactics (PXDX) as they will soon require submission of clinical documentation to support reimbursement for modifier 25 through a pre-payment determination process. And don’t even get us started on how they plan to man the dedicated fax-line. Prepare now for the massive influx of Cigna denials.
Cigna’s unscrupulous business practices are comparable to how casinos run their operations. The slot machines and house games are all meticulously designed to stack the odds against you through probability theory. Except in Cigna’s case – we are talking about medical providers and patient lives. So, for the last 10+ years, Cigna has been using an algorithm that was methodically designed for the sole purpose of lining their own pockets. As the old saying goes – the house always wins!
Here are my Pro-Tips for Challenging the Establishment:
- Stay committed to preserving a strong culture of compliance. Compliance professionals possess healthcare business acumen that makes us more valuable than ever.
- Always code to the highest level of specificity (especially diagnosis coding). The Cigna algorithm (PXDX) was designed to automatically deny suspicious code combinations (e.g., diagnosis not related to test/procedure).
- Use all resources at your disposal – provider representatives, network management, all levels of appeals, etc.
- Hit them where it hurts. Enlist your patients to escalate and file appeals when necessary. The health plan has legal obligations to their customers – patients.
- Don’t take no for an answer if you know you are entitled to payer reimbursement. Cigna systematically denying claims and disguising them as “medical necessity” denials should not be taken at face value. Show them why care is medically necessary and inundate them with peer-reviewed literature supporting your position.
- Determine which services are worth the appeal and then flood them with appeals. The payers are banking on the fact that the administrative expense will dissuade you from appealing denials. Appeal, rinse, and repeat.
- Evaluate your managed care payer contracts. Ask the tough questions – is this an insurer you want to be in-network with? What has your experience been with them thus far? What percentage of revenue do they represent for your practice? How much do you have to spend in administrative cost to collect from the payer?
- If your organization offers group health insurance, let your employer know you are not happy with the insurer and better options should be explored. You must hit insurers in their pockets to create change.
- Consult with a seasoned attorney regarding potential bad faith disputes when you feel an insurance company has not met their legal or contractual obligations.
- When necessary, contact your state insurance commissioner and file a complaint. I’d be willing to bet that the ProPublica story just barely scratches the surface. More investigations will be coming. And we all know this story is not exclusive to Cigna and encompasses MANY other health insurance companies.
Your next steps:
- Contact NAMAS to discuss your organization’s coding and documentation practices.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
Looking to start up a medical practice or grow your existing practice? Contact our parent company, DoctorsManagement.