Congressional committee, regulators question Cigna system that allows its doctors to deny claims without reading patient files

A major congressional committee on Tuesday asked insurance giant Cigna to provide company records so lawmakers can look into the company’s practice of denying health care claims without ever opening a medical record.

The House Energy and Commerce Committee has joined several state and federal regulators in examining the legality of Cigna by declining payment of certain claims using a system known as PXDX.

Rep. Cathy McMorris Rodgers, a Washington Republican who chairs the committee, noted that members of Cignas Medicare Advantage plans appeal about one in five denials of requests for medical procedures, known as prior authorizations. Of these denials, about 80% are overturned.

If these figures are at all exemplary of Cignas’ commercial appeal and chargeback rates, they would suggest that the PXDX review process is leading policyholders to pay out-of-pocket for medical care that should be covered by their health insurance contract. Rodgers wrote in a letter to Cigna.

The letter follows an investigation by ProPublica and The Capitol Forum that found Cigna doctors withheld payment for certain tests and procedures by automatically labeling them as medically unnecessary. In two months last year, Cigna doctors declined to pay 300,000 claims using the PXDX system, spending an average of 1.2 seconds on each case, according to internal spreadsheets that tracked how fast they worked .

A Cigna spokesperson said on Tuesday that the company welcomes the opportunity to fully explain our PxDx process to regulators and correct the many mischaracterizations and misleading perceptions created by the ProPublicas article.

Following publication, Cigna provided four examples of what it called misinformation and omitted facts.

Cigna said ProPublica incorrectly described the company’s denial of claims as a denial of care. The story goes unsaid and quotes Cigna as saying the rejections were for treatment payments.

The statement said ProPublica reported doctors were incentivized to withhold treatment. History doesn’t say that either.

Cigna also said the ProPublica story creates the impression that the company saved billions of dollars by using denials to boost profits. He said all the savings were passed on to the customers. ProPublica quoted an expert who developed PXDX as saying the system saved so much money. Cigna has not provided evidence of its savings or how much has been passed on to customers.

Finally, the company said that ProPublica’s story has left the impression that Cigna uses the PXDX process on all health care claims. The story explicitly stated that not all requests are processed through this review system.

In the past, Cigna has said the PXDX system was built to process claims faster.

But state insurance commissioners contacted in recent weeks have criticized Cigna, with several saying they want to take a closer look at the company’s use of algorithms to deny claims.

Mike Kreidler, the Washington insurance commissioner, said it was a repugnant practice to systematically deny it just to boost profits.

Kreidler said he and other state insurance regulators are reviewing their records for customer complaints that appear to depict an automated denial process.

I fear it may be the tip of the iceberg, he said. We damn well better start paying attention to it.

Industry sources told news outlets that other big insurers operate similar systems.

The investigation by ProPublica and The Capitol Forum has also raised red flags in California.

The California Department of Insurance said in a statement it is closely examining how health insurance companies handle claims, while exploring all options in coordination with other state regulators.

Other state insurance commissions also said they are interested in a more thorough examination of Cignas’ practices.

Given your article, this one probably deserves a closer look, said a spokesperson for the Delaware Department of Insurance.

The U.S. Department of Labor regulates a common type of insurance owned by many Americans: employer-sponsored plans that cover their own health care costs. Federal officials said they are alarmed by self-denial practices.

This is very worrying, said a senior Labor Department official who asked not to be named to speak on a sensitive issue. I don’t see a scenario where we’re not looking closely at these types of practices.

Two organizations accredit health insurers to make sure plans meet certain standards. Both of these groups, the Utilization Review Accreditation Commission and the National Committee for Quality Assurance, have launched investigations into the waste system. They did not immediately respond to detailed questions about the investigation.

The letter from the Energy and Commerce committee asked the company to turn over copies of all memoranda examining the legality of the PXDX review process.

The required records include details of the number of claims denied using PXDX, the number denied by individual medical directors employed by the insurer, and details of how often those decisions have been appealed and reversed.