Communications of the ACM
Cigna Accused of Improperly Rejecting Thousands of Patient Claims Using Algorithm
A federal lawsuit alleges the health insurance giant CIGNA used a computer algorithm to automatically reject hundreds of thousands of patient claims without examining them individually, as required by California law.
Credit: Matt Rourke/AP
A federal class-action lawsuit accuses health insurer Cigna of using a computer algorithm to automatically reject hundreds of thousands of patient claims without auditing them individually, as California law mandates.
The plaintiffs allege Cigna used its procedure-to-diagnosis (PXDX) algorithm to determine claims' legitimacy, spending an average of 1.2 seconds on each review, as part of an "illegal scheme to systematically, wrongfully, and automatically" deny claims to avoid covering medical necessary procedures.
The lawsuit argues that PXDX allows Cigna's physicians to "instantly reject claims on medical grounds without ever opening patient files, leaving thousands of patients effectively without coverage and with unexpected bills."
Cigna counters that the technology expedites reimbursement to doctors for common, relatively inexpensive procedures via an industry-standard review by confirming the submission of appropriate codes for these procedures "based on our publicly available coverage policies."
From Associated Press
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