Cigna saves millions by having its doctors reject claims without reading them

From the doctor's name and the Midwest area code for review center we were able to filter down the doctor's name to a single individual and then do a search in the state medical board system (I'm not sure if this is readily available to non-medical personnel). That popped up his med school, residency, work history (ended more than a year before) and some pending issues with his performance. When we replied by registered mail we made an obvious CC to a local lawyer.

Speaking to the surgeon we were also able to makes some guesses as to the rough name/title of a justification document they would use and that along with the citation number in a google search popped up a downloadable pdf which was 5-6 years old, but seemed about right. And when we looked up the paragraph and rejection it was pretty clearly related to roughly the right kind of surgery. That let us make a more focused/documented appeal to the rejection. When they finally approved we got a bit more documentation about the prior rejections and who reviewed them. I assume ass covering.

In the end the thing that really pissed me off is that they didn't even pay what they promised to and we knew it would another 100hrs of work to get it.

Edit: we paid ~10% out of pocket on a $60k surgery + their shortchange. good news is 15y later totally successful and healthy! P.s. this is by memory but somewhere we’ve still got that notebook and all the paperwork filed that I’d rather forget.

My sister was the manager of a coffee franchise named after a certain character from classic literature. Her location was doing extremely well, she was a competent type-A who commanded a great deal of respect in her entire district, and was generally assumed to on the fast-track for promotion.

One day, $200 was missing from her daily cash. She was fired the next day. Not for the missing money; they came showed her a list of very minor issue (clerical errors, an unwashed countertop on a random inspection, a couple unhappy customer feedbacks) that had come up in her eight-year career, and said she was fired for general incompetence.

Two weeks later, one of her ex-employees called up, crying; she was doing her laundry, and found $200 in one of her pockets. She had gone to the safe to make change for the register and screwed up.

The point here is: corporations understand that you can't fire someone or deny coverage based on reasons that can be contested. It's not fraud if you fire them for some other reason. It's not fraud if you don't even know why you denied coverage. You're only in trouble if you play fair.

We’re Americans and we love this sht and it's no wonder the CEO of that coffee company thought he deserved to be President.

Corporate counsel for insurance companies comprise one of the very few spots on the brontosaurus with low-latency innervation from the brain. Poke it, you'll usually get a response that will arrive faster than the usual appeals processes.

What can be done?

Instead of paying monthly insurance premiums, the company directly funds the claim payments as they come in. They outsource the work of adjudicating claims, negotiating with providers/facilities, cutting checks, setting approval criteria and first level appeals to another company, called a Third Party Administrator.

Now, who happens to have all the skills and expertise to do the job of a TPA? The big health insurers. These are giant companies with many lines of business. One of those lines is selling insurance to individuals and small businesses, another is selling administrative services to larger ones.

Note that even with a self-insured plan, there’s often insurance involved too: the company will buy a separate “stop-loss” policy that kicks in and starts paying after the employer has paid out a certain amount in total over a year. This protects them from the risk of covering a plan member with a particularly expensive condition.

I was simply trying to say that, within the confines of the current system, this particular actor has not gone out of their way to fuck me over in the same way that I hear about so many other actors.

I have no idea if my experience with Aetna is common or an outlier. My hope was that by posting this, it would provide a data point for people forced to choose a private health insurance provider in the future. I also hoped to hear from others who had experiences either mirroring or opposite my own.

If I could, I would dismantle our current system in a heartbeat and replace it with some form of single-payer. I can’t, so I tried to provide information about one player within the incredibly fucked up system Americans are forced to operate within.

I don’t and neither do the hundreds of millions of others who remain in the US. So for those people, I wanted to provide a data point that might help them when they, like me, are forced to make decisions about their healthcare in this system.

Please do!

My point was simply to say that this option is one that has done right by me so far. If there is significant evidence this is an outlier experience, I (and I’m sure others) would benefit from knowing so.

They talk about serving the patients, but payors are who pay the bill.

"Superior outcome" = Careful dance between aggregate average outcome vs total cost of care. It's a typical insurance industry doublespeak, and an very effective way to sell to payors.

the tweeter thread shows devastating images . the point is that a provider like that, has no business denying coverage. plus apparently he was not board cert and other issues from lapses in licensing

There are some restrictions on pre-auths and when an insurer can require one. If you are in need of immediate care to save your life, they are not required and your provider will give you care before even telling your insurance company about it.

The grey area with pre-auths is with nonemergency care that could lengthen someone’s life. There are requirements by law for appealing these denials but yes, this is where those stories about “I can’t get my cancer treatment” come from.

This is not the situations in the article, though.

What’s shitty about the actions in the article is that many people don’t even realize that erroneous health insurance denials are common and they just accept the denial and pay out of pocket. It is very common to get a denial, send in a challenge like “no this should be covered” and then they pay.

So, I don’t think I’d exempt claim denials from my proposed regulation. Named doctor, personally and professionally liable from the consequences of their denial.

Here is what it is for California:

https://www.mbc.ca.gov/Consumers/File-a-Complaint/complaint-...

https://www.mbc.ca.gov/FAQs/?cat=Complaint&topic=Complaint:%...

  What kinds of complaints warrant a formal investigation?

   In general, any complaint that would warrant disciplinary action if 
   substantiated (e.g., sexual misconduct, gross negligence and/or 
   incompetence, etc.) is referred for investigation. Other kinds of 
   complaints may also require a formal investigation. These include physician 
   impairment, unprofessional conduct and unlicensed practice issues.

https://www.kff.org/report-section/ehbs-2022-section-1-cost-...

No, you cannot prescribe mainstream drugs (some of it which are indeed useful) if you are not licensed. Cannot do surgery etc, either. All of it is 'illegal'.

>A 'free market' as you state just results in people falling for bullshit care.

True, what's different now?

So the exact opposite of what people usually mean when they say they want public healthcare.

Words mean something.

This process obviously does nothing to alleviate any medical issue, so you come back a few weeks later. You pay your $20. New doctor this time, who asks what meds you are on, takes your blood pressure and orders the same tests.

Obviously testing the same thing a second time didn't further the investigation. So you go back. You pay your $20. Yet another doctor this time, who asks what meds you are on, takes your blood pressure and orders the same goddamn tests.

Rinse and repeat. I've had like five of these contacts the last few years. Starting to look like a heroin junkie from all the blood samples. I've never learned of any test results. Just keep taking the same tests over and over. There is just zero continuity.

You may experience more pain compared to some other healthcare systems. Like France from my experience and probably USA from what I read.

I had some unforgettable experiences in Norway, such as a colonoscopy without sedation or anaesthesia in case I can tolerate the pain. I didn’t after a while.

Or some little operation that according to the English Wikipedia is done under general anaesthesia in USA. The doctor in my local small emergency room simply told me that the needle for a local anesthesia would be as painful as the operation so it’s unnecessary. She then asked a large nurse to hold me and I was given instructions about how to breathe. I think the doctor may have lied about the pain.

But I pay between $20 and $40 per visit and I don’t have to pay if it accumulates more than $300 per year. It’s also not connected to my work, I can be fired and still have the same healthcare benefits, forever.

The one benefit (I guess) of universal coverage is that doctors already know the unapproved medicines won't get paid for, so they never try. So you avoid the whole issue of rejections. They just go with whatever the system says it will pay for.

If you have no competition, the problem shifts the other way. The MRI machine is ten years old, so buy a new one even if it still works, because there is no competition so nothing stops them from raising premiums to pay for it. Then the MRI manufacturer declares that they're only supported for five years and by the way the price has gone up, because they know the non-profit isn't price-sensitive and the patients have no other choice. (Unless you put government pressure on them to keep costs down, and then you're back to cost cutting.)

The underlying problem is that you need an objective way to measure whether some cost is worth incurring. The best metric we have for that is whether the patient is willing to pay that amount of money for it, having been informed of the consequences by their doctor. Sometimes the answer is no -- it really might not be worth spending a million dollars to extend the life of a 78-year-old by six months.

But it probably is worth spending $100,000 to extend the life of an 8-year-old by 70 years, even if the 8-year-old doesn't have $100,000. Which is where you want some kind of insurance.

Where we screwed up is in making "insurance" cover minor procedures that really ought to only cost tens to hundreds of dollars out of pocket, because then the insurance causes those costs to balloon up to thousands by providing a deep pocket that can fund excessive bureaucratic inefficiency. (It also doesn't help that the AMA engineered a doctor shortage so now doctors are overworked, patients are less informed and prices are higher because of supply and demand.)

Check out the insurance companies profits. Those are directly linked to denied customer claims. Claims are not denied en-mass, by accident obviously - unless you're a complete fool.

So I guess it depends on where (city/state) you live and also what type of insurance you have.

Where I live I have access to a SOTA network of hospitals with great technology and some practices amount the best in the world (people come here from other states and even countries for treatment) and I use their own insurance, so it's been great so far, never dealt with any issues having medical care rejected.

I pay $350/month (self employed) and I have a very reasonable deductible, $60 copay to see specialists and many preventive procedures such as cancer and heart disease screenings (which I use), blood work and some PT sessions completely free.

I even get discounts on fitness centers and health tracking apps which helps offset part of the premium.

My shoulder was actually spared from a very invasive surgery thanks to a doctor top of his field (he sees olympic teams) who was able to treat me with only PT.

I don't think I paid more than $1000 out of pocket for everything including several MRIs and multiple visits to his practice, plus several sessions of PT and medications.

It could have been free back in my country, I guess, but I could have also been screwed for life due to an unnecessary surgery.

If I was in a public system, I’d fear I’d be fighting for attention alongside the general public, so I’m not convinced it would be better.

It's a well-known trope (probably proven, but I don't know the studies) that insurance companies routinely delay healthcare to AIDS and other patients with terminal diseases, in the direct hope that the patient dies.

With AIDS patients, there's a big moral component to the diagnoses, and companies can "get away with it," because there's such stigma to the disease, but I have also heard of the same thing happening to cancer patients. In fact, it can sometimes be a matter of life and death. If a treatment is delayed enough, it can change the outcome.

I have been told (but don't know it for a fact) that this is actually the point of the delays, and that the delays are triggered by the diagnosis.

In many cases, delaying payment, also delays treatment. Most patients don't have an extra 500K, floating around, that they can pay the hospital for a procedure, in the hope they get reimbursed. No promise of payment, no treatment.

So that means that refusal to pay is the same as withholding treatment, and these companies know it.

I think that AI is likely to make this worse, as they will probably give these decisions to an AI, thus removing any hope that there may be a caring human in the process that could possibly feel shame.

Note: I happen to have private healthcare with Cigna in a country with a reasonably good public health system (Spain, though it varies between different autonomous communities), happy to pay the taxes and will defend that public health systems are a staple of any modern country.

To be clear, we are talking about benefit to the patient; there's lots of reasons concierge doctors may not be the best benefit for society at large. But that's immaterial because this is just one example; if we hadn't gone for the worst possible way to scale private medicine, then there could be better examples.

But the point is that you can't seriously look at concierge doctors and say that public healthcare would be better for those patients! And therefore this refutes any claim that public healthcare is the best system overall.

Can you explain to me how the government telling you "you must do business with one of these insurers or else" is in any way a free market?

That’s one of many many examples.

The trip to the EU, a vacation, and the MRI itself would be cheaper...

I was actually planning on getting it done on my next trip to China, which is about the same cost wise, and the doctors are good as they see so many people lol

It is a joke.

Heck, WITH insurance you can expect it to cost up to around $1000 depending on coverage.

The real kicker is that you generally can't even find out this price until you have the procedure and receive the bill. It's become almost akin to a legal mafia cartel. In my area, a majority of the urologists have become part of a medical group that now dictates pricing for related procedures. Most of the major insurance carriers don't want to pay this pricing so this group is not a covered provider, so finding a urologist that is covered entails sometimes waits of months for an appointment.

It's the worst parts of socialized and for-profit health care assembled into one system.

Maybe because it's a politicized topic? How can you smugly dismiss their point like that?

Actuaries know, in aggregate, what specific demographics will need. Insurance companies use those statistics to make profit. The view that consumers cannot make informed choices on healthcare needs is incompatible with the fact that risks are not perfectly and uniformly random. Unless, by “informed choice”, you mean one that is correct in hindsight, in which case, I agree.

It’s not so great for those in the middle.

There is no fun surprises like finding out that while your surgeon and hopsital were in-network your anaesthetist was out of network.

When I was starting my career, I had to go to an ER that was out of network, I checked with my insurance and they said they would cover it. They decided after all not to honor their word and charged me 10’s of thousands of dollars.

Being young and independent, this was devastating, despite having a good job, good insurance, etc.

I largely credit this with my push to move to Europe, and have never looked back.

Sometimes knowing you can get any healthcare you need without it potentially a bankrupting you is it’s own reward.

So for an individual, it is roughly a $10k per year benefit to get it via employer and for a family of 4, $40k per year benefit.

It’s astonishing how much market inefficiency we’re willing to tolerate.

You can get rid of half the employees and cut everyone’s pay by half, and it won’t make much difference.

I think the US’s biggest problem in healthcare is liability. Every entity is spending so many resources on making sure that they do not get blamed in the event there is a lawsuit, because the damages are huge.

In countries with taxpayer funded healthcare, this liability issue is much less because you are dealing with the government only and suddenly liability and damage amounts are reduced.