Doctors at a major US insurance company deny tens of thousands of claims a month without even looking at patients’ files.

“We literally click & submit,” a former Cigna doctor told @ProPublica & The Capitol Forum. “It takes all of 10 seconds to do 50 at a time.”

The inside story 🧵

2/ Nick van Terheyden was puzzled when Cigna told him it wouldn’t cover the cost of a simple blood test, which it deemed “not medically necessary.”

“This was a clinical decision being second-guessed by someone with no knowledge of me.'

3/ Nick's unease was justified. His claim was just one of ~60,000 rejected in just a month by Dr. Cheryl Dopke, a Cigna-employed medical director responsible for deciding whether patient claims will be paid or rejected.
propublica.org/article/cigna-…

4/ And Dopke wasn't alone. A review of internal Cigna records turned up multiple medical directors who were rejecting a large volume of claims. Here are the Jan. 2022 rejection stats for 3 Cigna-employed doctors:

5/ How could these doctors possibly review and reject so many claims in a month?

With the help of a process called PXDX that allows Cigna docs to deny claims as medically unnecessary without having to open a patient's file.

6/ PXDX, short for procedure-to-diagnosis, uses a list of tests & procedures approved for use with certain illnesses.

It automatically approves claims that match the conditions, but also flags for denial treatments that don’t match one of the listed conditions.

7/ Medical directors can then approve the denials without opening a patient file.

In Jan. 2022 alone, Cigna medical directors used PXDX to reject more than 150,000 claims, spending an average of 1.2 seconds per denial.