[A doctor’s] claim was just one of roughly 60,000 that [medical director Dr.] Dopke denied in a single month last year, according to internal Cigna records reviewed by ProPublica and The Capitol Forum.
The rejection of van Terheyden’s claim was typical for Cigna, one of the country’s largest insurers. The company has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials. Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show. * * *
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[A] computer does the work. 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.
“We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.”
[My comment: I find it hard to believe that doctors could conduct meaningful review of claims in 1.2 seconds or could reach an appropriate professional judgment about 60,000 claims in a month. This reminds me of the way some lawyers approved lawyer letters in debt collection cases before the courts interpreted the FDCPA as requiring that attorneys conduct a meaningful review of the matter before sending letters to debtors. It is also reminiscent of the investigations some furnishers conduct when consumers complain about items on their credit reports. ]