Cigna saves millions by having its doctors reject claims without reading them • Hacker News Board

Re: Cigna saves millions by having its doctors reject claims without reading them

#61

Post by kurthr » Sat, Mar 25, 2023, 7:25 PM UTC

anigbrowl wrote: post #27

kurthr wrote: post #13

Earlier quoted context omitted.

Wife is a nurse. Required surgery for lifesaving/severe disability (inherited congenital, killed her father). Insurance was Aetna and Hospital Self Insured. Surgery recommended by world class surgeon she worked with. Finally pre-approved on 3rd appeal after 8 months and 150pages of documentation of every piece of every single communication (who, when, response, expected next contact) only weeks before surgery schedul…

Standard answer is we can't tell you why you were rejected How did you find out about the automatic rejection/identity of the reviewers?

That is a good question. The first appeal was "free" so we didn't have to justify it with anything other than, "no really the surgery is necessary". They only gave us a rejection number on the second and third rejections and we had to request the written forms by mail, which took weeks. The written form didn't have much more, mostly boiler plate, but it did have the number (and maybe a chapter/paragraph number citation?) and on the second one it had a signature by the reviewing doctor along with his typed name, which was luckily relatively uncommon. We had to provide statements from our doctors and surgeon (who also didn't get a reason for the refusal) justifying the surgery's need and effectiveness.

From the doctor's name and the Midwest area code for review center we were able to filter down the doctor's name to a single individual and then do a search in the state medical board system (I'm not sure if this is readily available to non-medical personnel). That popped up his med school, residency, work history (ended more than a year before) and some pending issues with his performance. When we replied by registered mail we made an obvious CC to a local lawyer.

Speaking to the surgeon we were also able to makes some guesses as to the rough name/title of a justification document they would use and that along with the citation number in a google search popped up a downloadable pdf which was 5-6 years old, but seemed about right. And when we looked up the paragraph and rejection it was pretty clearly related to roughly the right kind of surgery. That let us make a more focused/documented appeal to the rejection. When they finally approved we got a bit more documentation about the prior rejections and who reviewed them. I assume ass covering.

In the end the thing that really pissed me off is that they didn't even pay what they promised to and we knew it would another 100hrs of work to get it.

Edit: we paid ~10% out of pocket on a $60k surgery + their shortchange. good news is 15y later totally successful and healthy! P.s. this is by memory but somewhere we’ve still got that notebook and all the paperwork filed that I’d rather forget.

Re: Cigna saves millions by having its doctors reject claims without reading them

#62

Post by p_l » Sat, Mar 25, 2023, 7:26 PM UTC

luckylion wrote: post #21

hestefisk wrote: post #15

This is the reason we need universal public healthcare.

That won't help you there. Germany's public healthcare system denies plenty of things too, and will only pay for treatment when you sue (or know someone who works there). Germany's private healthcare system on the other hand is usually better (I'm sure there are exceptions and some insurance company that sucks).

Having worked tangentially on AI that approved payments for outpatient ops for one of the companies involved in handling German health system...

The very basic design goal was that the AI system could only approve, not reject. The goal was that obvious cases should be auto-approved, and anything where the AI returned below a certain confidence value was booted back to human to make a decision (same as pre-AI).

So at least you get that.

Re: Cigna saves millions by having its doctors reject claims without reading them

#63

Post by soared » Sat, Mar 25, 2023, 7:27 PM UTC

lostmsu wrote: post #47

I am surprised commenters here did not read into the nuance: > 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. Before grabbing the pitchforks, it is important to be sure if their policy is rea…

It’s insane to trust an insurance company to make healthcare decisions. I was denied an MRI when I tore my hamstring off the bone, and so my doctor had zero info on what my treatment options should be. I went to physical therapy when I possibly should have had surgery.

I’d so much rather 10% of people overpay for unnecessary tests than the other 10% of people be denied potentially necessary care.

Re: Cigna saves millions by having its doctors reject claims without reading them

#64

Post by dwater » Sat, Mar 25, 2023, 7:27 PM UTC

xwdv wrote: post #52

nathan_compton wrote: post #48

Earlier quoted context omitted.

This might be true, but as someone who has lived in the U.S. and Europe I can say utterly unequivocally that I preferred Health Care in Europe. I wasn't even in one of the European countries with a great reputation for Health Care. Health Care in the U.S. isn't just bad, its outright fucking brutal. An elderly friend of mine recently fell and went to an urgent care where they couldn't get him into the x-ray machine.…

I’m fully insured and have always been well taken care of in the United States health care system. Never wait more than 30 minutes if I were in an emergency room, and usually I’m attended to within 10-15. Doctors appointments are easy to get, never paid much for prescriptions. If I was in a public system, I’d fear I’d be fighting for attention alongside the general public, so I’m not convinced it would be better.

How old are you and what are your insurance premiums and deductibles? Generally the US healthcare system works better the more money you have and the less risk you have.

Re: Cigna saves millions by having its doctors reject claims without reading them

#65

Post by vfclists » Sat, Mar 25, 2023, 7:27 PM UTC

There a few points to be made here:

1. The doctors who signed of on those batches should be sued for medical malpractice and negligence. Where is the AMA on this issue?

2. Why are the tests so expensive? All it requires is to add some chemicals to the blood sample or whatever and see if it changes color or something? $1000 of dollars?

3. Isn't there a trust relationship between Cigna and the doctors who authorize the tests? Does Cigna believe that some of its doctors have a relationship with the testing companies where they receive kickbacks for authorizing the tests?

4. The patients whose tests were signed of in batches must file a class action lawsuits against each doctor separately and Sigma. The doctors and Cigna are colluding in medical fraud. Even if subsequent indepth evaluations indicate that declining a tests was justified they should still be sued as they signed off the tests without actually doing the tests for real.

5. I think American doctors, their healthcare institutions and their medical schools have a serious problem with the medical ethics if so many doctors are that criminally minded.

Re: Cigna saves millions by having its doctors reject claims without reading them

#66

Post by JeremyBanks » Sat, Mar 25, 2023, 7:27 PM UTC

xwdv wrote: post #52

nathan_compton wrote: post #48

Earlier quoted context omitted.

This might be true, but as someone who has lived in the U.S. and Europe I can say utterly unequivocally that I preferred Health Care in Europe. I wasn't even in one of the European countries with a great reputation for Health Care. Health Care in the U.S. isn't just bad, its outright fucking brutal. An elderly friend of mine recently fell and went to an urgent care where they couldn't get him into the x-ray machine.…

I’m fully insured and have always been well taken care of in the United States health care system. Never wait more than 30 minutes if I were in an emergency room, and usually I’m attended to within 10-15. Doctors appointments are easy to get, never paid much for prescriptions. If I was in a public system, I’d fear I’d be fighting for attention alongside the general public, so I’m not convinced it would be better.

[dead]

Re: Cigna saves millions by having its doctors reject claims without reading them

#67

Post by lostmsu » Sat, Mar 25, 2023, 7:29 PM UTC

soared wrote: post #63

lostmsu wrote: post #47

I am surprised commenters here did not read into the nuance: > 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. Before grabbing the pitchforks, it is important to be sure if their policy is rea…

It’s insane to trust an insurance company to make healthcare decisions. I was denied an MRI when I tore my hamstring off the bone, and so my doctor had zero info on what my treatment options should be. I went to physical therapy when I possibly should have had surgery. I’d so much rather 10% of people overpay for unnecessary tests than the other 10% of people be denied potentially necessary care.

Oh, you can have that. Just pay 10x for insurance to cover your 10x more expensive tests.

Re: Cigna saves millions by having its doctors reject claims without reading them

#68

Post by indymike » Sat, Mar 25, 2023, 7:29 PM UTC

firstlink wrote: post #43

indymike wrote: post #36

Earlier quoted context omitted.

When someone in my family does not get pre-approved for care, I write a letter and and ask my physician to sign, and ask the other doctors at his practice to sign a letter that goes like this: "I beleive this procedure _____________ is medically necessary for __________. Time is of the essence, and this procedure should be performed as close to immediately as possible." In the signature block, I include the degree, s…

This must have been before insurers adopted the mantra "we aren't denying care, only paying for the care!" With that legal magic wand, there is no risk to the insurer.

That was in full effect at the time. They would like for this to be the case, but reality is very different.

Re: Cigna saves millions by having its doctors reject claims without reading them

#69

Post by stouset » Sat, Mar 25, 2023, 7:30 PM UTC

blakesterz wrote: post #5

“We thought it might fall into a legal gray zone,” said the former Cigna official, who helped conceive the program. “We sent the idea to legal, and they sent it back saying it was OK.” Reading this article is just maddening. I've been dealing with different insurers for the past 7 years or so, and it's my experience they must all do something similar. Anyone with any kind of serious health condition is regularly driv…

Counterpoint.

I have an Aetna PPO and experienced a stroke last year. $100,000+ hospital stay and insurance just… covered it. I paid $1,100 out of pocket.

I had a $100,000+ surgery a few weeks ago to repair a heart issue that may have led to it. They just covered it. No fuss, no hassle. I paid $3,300, which was the remainder of my total annual out-of-pocket, and now I will pay $0 for healthcare for the rest of the year.

For the surgery, I called in advance to double check that it was covered and after five minutes on the phone with a concierge they confirmed that it would be covered.

Obviously I am only a single data point and I can’t speak towards other conditions or procedures. But Aetna has done right by me, at least from within the perspective of our insane for-profit healthcare system.

Re: Cigna saves millions by having its doctors reject claims without reading them

#70

Post by anigbrowl » Sat, Mar 25, 2023, 7:31 PM UTC

kurthr wrote: post #61

anigbrowl wrote: post #27

Earlier quoted context omitted.

Standard answer is we can't tell you why you were rejected How did you find out about the automatic rejection/identity of the reviewers?

That is a good question. The first appeal was "free" so we didn't have to justify it with anything other than, "no really the surgery is necessary". They only gave us a rejection number on the second and third rejections and we had to request the written forms by mail, which took weeks. The written form didn't have much more, mostly boiler plate, but it did have the number (and maybe a chapter/paragraph number citati…

Good grief. I'm sorry you had to go through that, the bureaucratic trauma involved in health billing/insurance increasingly seems as bad as or worse than the medical issue itself.