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Diving brief:
- Cigna faces a second class-action lawsuit over the health insurer’s use of software to automate claims processing.
- The lawsuit filed in Connecticut District Court In late August, it was alleged that Cigna’s “diagnostic procedure” or PxDx software reviewed and denied customer claims in batches without a medical professional reviewing those decisions.
- Faces of Cigna an almost identical trial in California which was filed earlier this summer. The payer is championing the technology as a standard review process similar to those used by other insurers.
Dive overview:
Cigna has been under fire for its use of automated claims processing software since the start of the year, after a ProPublica investigation found that Cigna doctors used PxDx to automatically reject claims without opening the patient file.
The House Energy and Commerce Committee and state regulators are investigating Cigna’s use of the software, and in July, two Cigna members in California sued the payer, alleging that had illegally denied them payment due to PxDx.
The algorithm works by flagging discrepancies between a diagnosis and what Cigna considers acceptable tests and procedures for that disease. The lawsuits allege that the Connecticut-based payer used the technology to deny payment to hundreds or thousands of people at a time.
That lawsuit — and the new suit filed in Connecticut — both cite ProPublica’s findings that PxDx was used to reject more than 300,000 payment requests over two months in 2022. The average time taken to deny each request does not was only 1.2 seconds.
The plaintiff in the Connecticut lawsuit alleges that she was denied reimbursement for a medically necessary colonoscopy and endoscopy because Cigna “automatically and algorithmically denied claims.”
Insurance laws and regulations in many states require review of medical records before payers will deny claims for medical reasons. Connecticut law requires health insurers to conduct a “reasonable investigation based on all available information.”
In response to the new lawsuit, a Cigna spokesperson directed Healthcare Dive to the payer. previous public statement on PxDx allegations.
“This copycat lawsuit is without merit,” the spokesperson added. “Based on our research, the allegation in the complaint was not subject to Cigna’s PxDx review, and the complaint appears to be based on an article riddled with factual errors and misinformation. »
The lawsuit filed in Connecticut seeks class-action status covering every individual nationwide whose claims were investigated using PxDx.
The exact size of this group is unknown but could be significant: Currently, the payer provides health coverage to 19.5 million people in the United States.
