Cigna is Murdering People

Introduction

Sentia does business with a large number of practices and one of them recently brought to our attention that Cigna frequently just forgets that it has negotiated rates with practices and pays whatever it likes, but of course never higher than it should be.  With a little research this seems to be the tip of the iceberg.  They are also simply rejecting claims as well.  We will discuss some possible reasons for this, and probable fixes for it.

Possible Reasons

There are only two possible reasons to deny or underpay valid claims: malfeasance or incompetence.  Before we discuss that though, let’s take a look at the process itself.

The Process

First, your insurance company, all of them, negotiate a rate with the practice your doctor is a member of.  These rates are, of course, lower than your doctor wants to accept in an effort to cut down on the cost of healthcare.  Sentia would say that any savings achieved this way would be eaten by lawyers and negotiating, but that is not the topic here.  Now, we have a negotiated rate.  When your practitioner performs a procedure, they submit a claim or bill to your insurance company, for payment of the negotiated rate.  The insurance company then adjudicates or looks for any way possible to deny the claim.  This is not snark.  They all look for ways to avoid payment, that is the way they perceive their business.  Normally, then, if they can’t find a good reason, then they pay the claim.

The Problem

Cigna has been caught hundreds of thousands of times both denying and underpaying valid claims.

Incompetence

We here at Sentia like to give the benefit of the doubt and try to believe the best about people.  With that in mind, let’s assume that Cigna isn’t just stealing money.  Let’s assume that their old, antiquated, manual, spreadsheet-based processes simply can’t keep up with the volume of policies they have to service.  Let’s assume that somewhere in the adjudication process that claims just fall through the cracks and get timed out instead of rejected.  That doesn’t really sound plausible to me, if they have an automated timeout, they should probably have an automated approval, and clearly that is not the case.

Malfeasance

ProPublica wrote an exposé in 2023 detailing how Cigna rejects claims without ever even looking at them individually.  Apparently, they hire doctors, that you pay for, to reject claims in batches.  In one case a doctor rejected over 60,000 claims in a year, averaging 1.5 seconds per claim and almost 200 per day. From the article:

“We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.”

 Go read the whole article.

The Associated Press did a similar exposé claiming that Cigna erroneously rejected more than 300,000 payment claims in just two months in 2022 in California alone.  Cigna has developed an algorithm to match diagnosis codes (ICD10) with procedure codes (CPT) and if your claim doesn’t match this list, your claim gets rejected for medical reasons and the doctors at Cigna just sign off on it.  From that article:

Ultimately, Cigna conducted an “illegal scheme to systematically, wrongfully and automatically” deny members claims to avoid paying for medical necessary procedures, the lawsuit contends.

The American Medical Association has a different problem.  They report that patients and physicians have filed a class action lawsuit against Cigna for underpayment of claims.  In the article they state:

The Litigation Center of the American Medical Association and State Medical Societies, the Medical Society of New Jersey (MSNJ) and the Washington State Medical Association (WSMA) in September became plaintiffs in the lawsuit alleging that Cigna failed to pay the medical claims based on physicians’ contracts with MultiPlan Corp.  Instead, Cigna applied its own, lower payment methodology for nonparticipating physicians and other health professionals. That move left patients exposed to balance billing for physician and other health service fees.

So, Which Is It?

It really doesn’t matter whether the algorithm is wrong, the spreadsheets are wrong or whether Cigna finds itself in a position where it has to quite literally cheat and steal to remain profitable with all their huge buildings in every major city, tens of thousands of employees and associated infrastructure.  The only point here is that they are denying valid claims, causing unnecessary and illegal financial burden on their clients and literally killing innocent people.

Consequently, the United States Department of Justice ruled that Cigna must pay $172 million to settle Medicare claims alone.  This only applies to Medicare Part C where patients can opt for obtaining their coverage through private insurers.  This is a tiny part of the overall cost to patients.  

The Solution

This is just one insurer out of the dozens operating in the US.  We are forced to imagine that some level of this incompetence or malfeasance is going on everywhere, or Cigna would put the other insurers out of business.  We here at Sentia side with Colin Chapman and his philosophy of “simplify and add lightness.”  If you’ve read our articles and seen our videos, you know that we advocate for, and have built, a new kind of health insurance company that provides the Medical Records System to the practice, free of charge, and then detects and pays for procedures performed in real time.  Since we have no big buildings or tens of thousands of employees and associated infrastructure, we can eliminate all this old, legacy insurance idiocy and replace it with a simple system that we maintain.  For the privilege of maintaining the patient data and paying their claims we expect a small data management fee of $10 per month.  Of course, we will add the actual cost of the incurred risk to that, but it should save the average patient almost half off his or her health insurance bill.  Just as important, those tens of thousands of employees we DO NOT have can’t be looking for reasons to deny claims.  If the doctor says you need it, then you need it.  We will have data scientists to ferret out fraudulent claims of course, to keep costs low, but after the initial research, that turns into a report that we can run with the click of a single button.  

Today we have shown two ways that old, legacy health insurance companies are defrauding their clients and murdering patients and given three examples of that.  We have also shown a way to literally put them out of business with a smart, simple program that automates everything that they are supposed to be doing.  We need your help to put this all in motion. We currently have a prototype system that works and that we can demonstrate.  We are starting on the production code.  Your job is to subscribe and share with everyone you know, generate buzz, make people talk about this, so that we can make this come to fruition.