Examining Cigna's Role in Healthcare Coverage Disputes

Institution

Course

Professor

Date
 Examining Cigna's Role in Healthcare Coverage Disputes

The piece focuses on a class-action lawsuit against the insurance provider Cigna, which is

accused of regularly rejecting patient-submitted health insurance claims after evaluating them

using the PxDx algorithm. By rejecting claims, PxDx helps the insurance company save money

(Picchi, 2023). This lawsuit claims that Cigna's actions are against California state law, which

requires insurers to evaluate each patient's claim in-depth, fairly, and objectively. The accusation

is that Cigna uses the algorithm to deny claims as a cost-cutting tool rather than having doctors

analyze each case individually. This circumstance begs the issue of whether algorithms can make

decisions as thorough and objective as those made by human medical practitioners. The case

highlights two incidents in particular. In one, an ultrasound was performed on a California lady

with Cigna insurance because she was worried about ovarian cancer. Cigna rejected her claim

even though she was medically necessary, leaving her with an unforeseen $723 payment. In

another incident, a Cigna customer's doctor had requested a vitamin D test, but the claim was

rejected without any justification.

The case emphasizes how computers and artificial intelligence play a larger role in jobs

traditionally handled by humans, notably in the healthcare industry. Opponents claim that these

automated systems might not provide as complete, fair, and unbiased judgment as human

specialists. The complaint contends that Cigna doctors who use the PxDx system only accept

claims on medical grounds after first evaluating patient files, possibly leaving many patients

without insurance and subject to unanticipated costs (Picchi, 2023). Surprisingly, Cigna doctors

used this strategy to reduce over 300,000 payment requests over two months 2022, devoting just

1.2 seconds on average to each. According to Cigna, which justified using PxDx, the technology

is employed to confirm codes for routine, affordable treatments using publicly available
coverage plans. They claim this procedure doesn't lead to treatment rejections and expedites

physician reimbursement. However, some patients discover they need help with expenses when

they think their health coverage covers them.

The article concludes by highlighting a legal dispute involving Cigna's use of an

algorithm to manage insurance claims, igniting a discussion about the role of automation in

deciding healthcare coverage and prices and highlighting the possible repercussions for patients.
 References

Picchi, A. (2023, July 26). Cigna accused of using an algorithm to automatically reject patient

claims - CBS News. Www.cbsnews.com. https://www.cbsnews.com/news/cigna-

algorithm-patient-claims-lawsuit/?ftag=CNM-00-10aac3a