Is a Major Health Insurer Rejecting Treatments Too Quickly?

For most people with private health insurance in the United States, getting certain procedures approved can require a few different steps — including getting both a doctor and your insurance provider to approve certain surgery or medication. If everyone involved signs off, you’re home free, but if not, you might need to go through an appeals process — or pay out of pocket.

It’s a phenomenon that’s been in the news a lot lately as it applies to weight loss drugs. But the issue is far more widespread than that — and a blockbuster new investigation from ProPublica has revealed what looks to an alarming policy from Cigna.

The report — written by Patrick Rucker, Maya Miller and David Armstrong — suggests that Cigna is denying massive amounts of insurance claims en masse. Citing “corporate documents and interviews with former Cigna officials,” the ProPublica investigation notes the existence of “a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file.”

The numbers cited in the report include 300,000 claims denied over the span of 2 months. According to the investigation, this isn’t the only system the insurer uses; this one works with a computer to identify what the company believes to be the incorrect treatment for a diagnosis.

How Will Architecture and Design Shape the Future of Healthcare?

From luxury care to emergency facilities

For their part, Cigna told ProPublica that the system was designed to “accelerate payment of claims for certain routine screenings.” But this investigation seems like it could be only a fraction of something much larger — a former insurance commissioner for the state of California felt that this program could be in conflict with state law. Could this investigation spark multiple investigations? It doesn’t seem out of the question.