when health insurance companies
deny claims, an appeal is not
likely.
Federal data shows companies
issued 49 million denials in
'21.
Customers appealed .2 of 1% of
them.
While some denials come with
specifics, most explanations are
vague.
Ally explores how one major
company is using ai to assess
and often deny claims in bulk.
Reporter: Investigative
journalist at pro-public a found
Cigna uses an automated system
to instantly reject claims on
medical grounds without opening
the customer file.
Summer accusing it of using the
system to help cut cost,
which Cigna denies.
Ryan Miller worked on this
story, Maia, thank you for
joining us.
Explain how the system works.
>> When you go to a doctor or
see your provider, they will
send in a claim to your health
insurance plan.
They will list the diagnosis
they think you have and tests or
procedures they want to run.
There is a process developed at
Cigna a decade ago in which they
created this code, computer
code, algorithm, that says we
will approve them if they match
certain conditions but if they
don't match another condition,
let's say a diagnosis, they
don't think is worthy of that
treatment, then it will be sent
to the desk of a medical
director, which is a company
doctor, and that Dr. Will be
able to quickly sign off on
rejecting that claim and saying
we are not going to cover it.
Last year that happened in under
two seconds.
These medical directors were
essentially saying for 50
patients at a time, they
wouldn't even open a file, but
they were signing their name
often saying, actually this
claim is not medically necessary
and so we are not going to cover
it.
>> I want to read from a
statement Cigna provided.
They say this automated progress
"Allows us to claim quickly and
allows directors time to look at
more complex reviews."
It also says "Even a denial
should not result in
out-of-pocket costs for patients
who are using in network
fighters -- in network
providers."
>> On the first statement, it's
true some of the claims that are
processed through the system,
which is called pxdx, if they
match diagnoses and treatments
on the list, if the code sees
there is a match, they will be
automatically approved.
However, there is about to them
that automatically denied.
That is what we are focusing on,
the batch of claims which we
found, in two months last year
exceeded 300,000 claims.
Not an insignificant amount.
To the second point about this
should not result in any
out-of-pocket costs for
patients.
Unfortunately the reality is,
oftentimes when we go to a
doctor, nurse or provider, we
often have to sign off on a form
and in that form we are saying,
we will take Christmas ability
financially for this -- we will
take responsibility financially
for this, so it often gets
shunted onto the patient.
>> What kind of treatments are
talking about that are getting
routinely denied?
>> Unfortunately, we were
looking for a comprehensive list
of these claims that processed
through the system.
We know not all of the claims
Cigna has ends up going through
the system but of those that do
we learned vitamin D testing is
labeled as part of the system.
Autonomic nervous system
testing, to test whether your
nerves are working well --
oftentimes if you have diabetes
or other autoimmune disease, you
can have some nerve damage in
your fingers and toes.
Testing to figure that out among
other conditions, unfortunately,
we could not find a
comprehensive list of all the
different procedures that are
tagged for the system but those
were to that we were able to
conclude.
>> Cigna and all insurers in
claims denials issues will say
there is always the eel process
-- the appeal process.
What does that look like in
reality?
>> One in seven claims are
denied across the country.
Health insurance claims.
It affects a lot of people.
One study found .1% of all
people who experience denials
actually took it to do a formal
appeal.
When you are going about your
day today, maybe you are facing
illness, a disease, a chronic
disease, it's hard to find the
time and wherewithal to figure
out how to appeal claims.
Reality is, very few people do.
We found through reporting,
Cigna had a presentation in
which they were putting forward
the idea to put on autonomic
nervous testing through the
system and in the cost-benefit
analysis assessing whether to do
this, they assumed 5% of
patients would end up appealing
this and that was part of the
calculation of whether to put
this test into this program or
to leave it out.
Reporter: Cigna is not the only
insurer with an automated system
like this.
Do you have a sense of how
prevalent automated systems are
right now in the health system
writ large?
>> It appears to be prevalent.
Insurance companies deal with
millions of claims.
In order to stay on top of this
and maintain efficiency which is
what they said, they have turned
to algorithms and computer
programs to process claims as
quickly and efficiently as
possible, is what they say.
It seems this kind of technology
is prevalent across the
industry, although we are still
reporting, for other insurance
plans, we are trying to confirm
that.
It seems pretty pervasive.
Reporter: There was a robust
debate happening about the
hazards of using ai.
Where does this conversation fit
into the broader debate about
utility and hazards of using
artificial intelligence?
>> Great question and one we are
posing to regulators right now.
The former insurance
commissioner of California, Dave
Jones, told us in the statutes,
you need to have a thorough,
fair and objective assessment of
patient claims and if a medical
director or company doctor for
an insurance plan is really
looking at a claim in less than
two seconds on average, can you
achieve that result?
I would pose that question to
the lawmakers, regulators, to
see where they would stand on
that.
>> My ML or, thank you for your
time.
>> Thanks for having me.