Doctor at Cigna said bosses pressured her to review patients' cases too quickly
propublica.org
propublica.org
One of the worst parts about this for me was that while I was dealing with trying to get my life back together from that kind of injury, I thought I was also going to go bankrupt as well.
In my case, everything did turn out fine because apparently the hospital has an entire department dedicated to dealing with insurance claim denials. This whole system is an absolute joke.
Of course the insurance companies always get the heat but it’s probably the minimum wage biller at the office that justified the bone set with an incorrect urinary tract infection diagnosis code that will obviously get denied.
In the future it’s useful to call the provider and ask for a copy of what they submitted to your insurance.
I have had a generous United Healthcare plan for 15 years. That time period included a high risk pregnancy, a spinal fusion, and a high risk cancer treatment program.
I’ve had zero billing issues. Zero. We did have some prescription formulary issues that were a result of some drugs being specialty drugs with a different process.
My sibling has Cigna, and literally has a problem of some sort with 80% of claims. The latest is an 8-year olds ear infection was determined by Cigna’s subrogation process to be related to a car accident.
> In the future it’s useful to call the provider and ask for a copy of what they submitted to your insurance.
If the practice tries to bill you anyway that’s called balance billing, is illegal, and violates their contract with your insurance company and you can call your insurance’s hotline to report them.
I knew someone whos wife got cancer. But good luck, she actually worked in the insurance industry and knew everything. Yet, it still turned into a Full Time job for her to get all the paper work corrected. How is the common person going to fight the system if insiders have difficulty.
I didn't realize that was mandated by law? Surely not down to individual codes?
If that is what you are talking about, it kind of makes sense. Part of how the industry obfuscates is by using a lot of different terminology for the same thing, thus nobody can do price comparison across vendors. But of course, trying to impose order onto something purposefully confusing, is going to be difficult.
It is possible to arraigned the codes in rather amusing orders such as:
I required a Face Transplant, from a Cadaver; “0WY20Z0 Transplantation of Face, Allogeneic, Open Approach Transplantation of Face, Allogeneic, Open Approach” after my many spacecraft crashes into the ocean; “V9541XD Spacecraft crash injuring occupant, subsequent encounter”.
Sadly the first Face Transplant failed so one was grown in a lab for the second Face Transplant; “0WY20Z1 Transplantation of Face, Syngeneic, Open Approach Transplantation of Face, Syngeneic, Open Approach”.
Alas all of this made my “F52 Sexual dysfunction not due to a substance or known physiological condition” became so bad that I tried to harm myself with a jellyfish; “T63622A Toxic effect of contact with other jellyfish, intentional self-harm, initial encounter”. -- Amusement with the Medicare ICD10 Billing Codes –
The law does not specifically require X12. The law gives CMS the authority to set technical standards and they chose X12 for those transactions because there was no other practical option. But recently they have granted at least one exception to use FHIR instead.
Sometimes a claim is denied because the insurer says they need additional documentation when that documentation was already provided. Sometimes this happens more than once. Sometimes prior authorization requests get "lost".
I think the problem is that if an insurer wrongly denies claims some of the time, nothing bad happens to them but they might save some money. The only fix I see is to change the rules of the system so that it the insurer gets no financial advantage for wrongly denying claims.
We've not hit this point overnight - it's been decades in the making. But I'm not sure we'll ever 'fix' this by small incremental reforms around the edges. We need some moonshot revolution, but I'm not sure we have enough collective appetite for that.
I'm not saying that the current system in the US is great, but moving to a 100% "single-payer" model will not get rid of claim review.
With the ever increasing ageing population, and stagnating economy, the pressure on the healthcare system balloons while the money pot is finite, so the existing resources keep getting split more and more aggressively creating a system of winners and losers. It's inevitable when the resources are finite but the demand virtually infinite.
“Everybody who supports single-payer health care says, ‘Look at all this money we would be saving from insurance and paperwork,’ ” the former President noted. “That represents one million, two million, three million jobs.” https://www.newyorker.com/books/under-review/the-bullshit-jo...
The change isn't something where you just pass a law / flip a switch, and everything is better. It's HARD.
I bet a ton of these bureaucratic approve/deny/request-more-information workflows in current EMR systems will be replaced by AI in a few years, putting the people out of work.
Once AI eats their jobs, less resistance to changing the system.
Trillionaires with killbot armies: "No, I'm not seeing what you're seeing at all"
The EU AI act prevents exactly this scenario.
bool should_approve_claim(int claim_id)
{
return false;
}I am now buidling an aprove deny API, going to call it dPANEL for deterministicPanel. Also chatGPT seems ungodly enthusiastic to help me build it...
Pricing Strategy for Health Insurance Approve || Deny API Pricing Structure Base Subscription Fee: Annual Subscription: $120,000 per year, covering up to 50,000 API calls. Volume-Based Pricing: Beyond the initial 50,000 calls: Tier 1: 50,001 to 100,000 calls at $1.50 per call. Tier 2: 100,001 to 200,000 calls at $1.25 per call. Tier 3: Over 200,001 calls at $1.00 per call. Multi-Year Discounts: 2-Year Contract: 10% discount on the annual subscription fee. 3-Year Contract or more: 15% discount on the annual subscription fee. Additional Services: Custom Integration: $30,000 one-time fee. Premium Support Package: $25,000 per year for dedicated support and quarterly performance reviews. Early Termination Benefits: Early termination within the first year incurs a 50% fee of the remaining contract value. Termination in the second year or later incurs a 25% fee of the remaining contract value. Cost-Saving Benefits Labor Cost Reduction: Automation of approval and denial processes reduces the need for manual labor. Increased Efficiency: Faster processing times improve operational efficiency and customer satisfaction. Error Reduction: Minimized human errors reduce costs related to claim reprocessing and disputes. Scalability: Efficiently manages varying loads without significant staffing changes. Regulatory Compliance: Helps ensure decisions are consistent and compliant, reducing potential fines. Data Insights: Offers valuable analytics that can lead to better risk management and operational adjustments.
Isn't this a flavor of the "broken window" fallacy?
There is more productive work these people can do than the adversarial "deny-fight-ok approve" system we have today.
I am not saying we shouldn’t try, but you really do need to think carefully about how to phase things in so people have time to adjust.
> “I don’t think in ideological terms. I never have,” Obama said, continuing on the healthcare theme. “Everybody who supports single-payer healthcare says, ‘Look at all this money we would be saving from insurance and paperwork.’ That represents 1 million, 2 million, 3 million jobs of people who are working at Blue Cross Blue Shield or Kaiser or other places. What are we doing with them? Where are we employing them?”
In my mind's eye is a political-style poster depicting the patriotic duty it is to pay your medical bill. Insurance company takes a cut, people who fight insurance companies take a cut, CEOs take a cut, everyone takes a cut, my medical bill is keeping half the nation afloat it seems, until at the end there's even a few dollars left over for the doctor. All because I spent 5 minutes talking to a doctor about an ear ache.
Fixing this will require eliminating a lot of these ancillary jobs and it won't be popular among those groups.
It does so because it can. It's the wealthiest country on Earth so such high inefficiencies where a lot of the money is squandered to the benefit of few wealthy and unscrupulous parties, can be financially absorbed while still delivering a system that's functional enough for its citizens to not revolt over and want to hang someone. After all, it's still better than scary communism.
Everyone has the same 100%, just distributed differently.
If Country A is spending 10% of it's GDP on 10 things, Country B cannot possibly outspend it in every category as a percentage of their respective GDPs, because "percentage of GDP" is always a 100-point scale.
If you go up one percent in one category, you have to go down one percent somewhere in the other categories.
I have seen the same with people I knew who had cancer. They are already super sick but are then in addition expected to navigate this insane system or accept to pay tens and hundreds thousands of dollars. All this while they can barely function at all.
Bad analogy. Speeding tickets carry no penalties to those who issue them wrongly. You can sue and if you win the local government will eventually pay for the damages, meaning the taxpayers, meaning also you. They have no skin in the game.
The point is that these companies should get hit several times a month with a bill till middle management sees it is a cost center and actually worries about "how do we bring down this number?" and it becomes a bigger problem than "how do we reduce our coffee budget?".
So, there should be misdiagnosis tickets.
By this logic, would you say that software engineers should be financially liable for any bugs they cause along with people who misdiagnose those bugs in the process of root cause?
In contrast, how do I even know my medical diagnosis was wrong? How do I know it could have been better given the facts at hand at the time? There also seems to be no market function at all that gives market feedback to the medical institution
Edit: procedures going wrong is of course already highly penalized and insurance for this is a significant cost of our health care.
Yes. Professional engineers are held ethically, professionally, and in some cases financially responsible for the work they sign off on. Personally, I agree with Dijkstra who pointed out in a speech in 1993 that the term "software engineer" is a hollow sham:
> And also the programming manager has found the euphemism with which to lend an air of respectability to what he does: “software engineering”...
> In the mean time, software engineering has become an almost empty term, as was nicely demonstrated by Data General who overnight promoted all its programmers to the exalted rank of “software engineer”! But for the managing community it was a godsend which now covers a brew of management, budgeting, sales, advertising and other forms of applied psychology.
> Ours is the task to remember (and to remind) that, in what is now called “software engineering”, not a single sound engineering principle is involved. (On the contrary: its spokesmen take the trouble of arguing the irrelevance of the engineering principles known.) Software Engineering as it is today is just humbug; from an academic —i.e. scientific and educational— point of view it is a sham, a fraud.
From https://www.cs.utexas.edu/users/EWD/transcriptions/EWD11xx/E...
People with known medical issues aren't really looking for insurance, they aren't pooling risk, they are sick. They need coverage. Businesses can easily handle insurance, but coverage is another matter. You are talking about people you know will cost more than they payout. That's charity, and better left to the state than the private sector.
Paying for health insurance premiums with pre tax dollars is tied to employers, or you can do it if you are self employed.
By and large, you can purchase the same health insurance that an employer offers on healthcare.gov, that meets the minimum ACA coverage standards.
However, there is no reason for employers to be able to compensate employees with pre tax dollars via subsidizing health insurance, but an individual cannot buy health insurance with pre tax dollars. That is just a handout to big businesses to give them an advantage over smaller businesses.
Also, employers compensating employees only in straight pay only also makes it easier for employees to compare compensation offers.
Now depends what happened, how much you sue for, but losing license and ending in jail are not impossible results. Its up to judge to decide. If that's not skin in the game then I don't know what is. Compared to 99.9% of IT folks who at worst can lose their jobs and move on (not ideal situation of course, but incomparable pressure for relatively similar compensation).
The incentivized behavior for insurance companiese right now isn't fast review, it's fast denial (which saves money on both review time and insurance payout). We need to make a coverage denial take an order of magnitude more time and effort than an approval, so insurance companies are forced to think real hard about denying access to care, and are incentivized to only deny care in relatively extreme cases.
Raise the bar for denial reasons, and forbid generic denial templates.
More difficult or more expensive. A random sample of denials being sent to a public board might do the trick, with a mandatory per-review fee charged to the insurer, and the sample size increasing as a function of reversed denials.
It should be a continuous stream of cases being randomly selected and reviewed.
Insurance is fundamentally incentivized to scam its own customers. We need to add more regulation/oversight to reduce situations where management can play tricks to tip the balance in their favor. It's an arms race.
The article was mostly about optimizing medical director "productivity levels", but it also mentioned that they outsourced to nurses in the Philippines who were doing a really bad job. Is there any oversight there? Are the nurses being incentivized to maximize denials? It'd be interesting to see how their productivity measurements are calculated too.
Of course nothing is going to change (because of something to do with "socialism" I bet), but at least now I know to avoid Cigna.
I mean it shouldn't be.
Imagine this; you have the choice between 2 insurance companies. One has a reputation of denying all claims and the other doesn't. Which do you pick for your insurance?
Whichever insurance is provided by my employer.
I'm sure there's a degree of thinly-veiled abstraction there. "Oh, we never specified such incentives for the outsourced nurses" ("... and while we did specify those incentives for their contract agency, we had NO idea that they'd put such incentives on their employees, none at all!")
The insurance companies are banking on most people not having the time, energy, or knowledge on how to push back on them. Having a service provider that can do this will cause those insurance companies untold amount of pain.
I suspect the real trick would be to keep insurance company lobbyists from finding a way to shut that down.
I’m sure they’re competent, but that sending these records to a foreign location where HIPAA does not exist is a matter of course should have people up in arms.
(I think it's probably a bad practice, but it's a legal one.)
Does the company risk being shut down?
Do the company officers personally face criminal charges?
What is interesting today is that Republicans campaigned for years on getting rid of Obamacare. When they finally got control of Congress and the Presidency they did not kill it. Eventually there will be another overhaul because these companies just can’t help but be shitty.
If you are a government leader and you offer healthcare to everyone, you are now clearly responsible for any failures. But with an MCO in the middle, fingers can be pointed all over the place.
Different formularies and prior authorization rules can be set for different populations. For example, reimbursement can be lower for Medicaid patients (poorer/younger people), so they end up with less access to doctors, and higher for Medicare (older, likelier to vote), so more doctors are available there. Senators can get their own plan, and the military another, and the tech company employees yet another, and fast food employees, and so on and so forth.
This system benefits all the leaders, so it is not going anywhere. In fact, I would bet UK and Canada move towards this.
I keep reading about NHS in the UK having issues holding it together.
I'm in the UK and yep, the system is on the verge of collapse, but it feels like it's entirely by design so it can be finally privatised and killed off once and for all - it feels inevitable at this point.
Basically right now it works for:
- maternity
- anything child related
- emergency services(to an extent, unless you are literally dying you will still wait hours for an ambulance).
Everything else is so massively underfunded it's a miracle it exists at all.
A friend was referred to see a psychiatrist on the NHS recently - you know what the wait time is to see a psychiatrist on the NHS in our region? 210 weeks. About 4 years.
Few which provide the level of care the upper middle class and above have come to expect in America. If you make more than $100 yo 167k (85th and 95th percentiles [1]), a good fraction of HN readers, you should be able to virtually walk into any medical establishment and get not only seen within a few days, but also tested and imaged by the latest technology, and consulted on by some of the best doctors in the world. You will do this without worrying about costs, because your employer has chosen an insurer who pitched on experience in addition to cost, because you have the market power to change jobs (or be heard by management) if your healthcare sucks.
Universal healthcare means everyone on a PPO falls to the middle class’s HMO-esque standards. For us privileged few, that’s a tough pill to swallow. That is the fundamental injustice and tradeoff that locks us into the status quo, not some paranoia about socialism.
[1] https://en.m.wikipedia.org/wiki/Affluence_in_the_United_Stat...
It was fear of socialism that caused the outrage at Clinton’s healthcare proposals. The fear and outrage was so great that for the first time in decades Republicans took control of the House of Representatives in 1994. Look up the number of times things being labeled communism and socialism has been used to try to halt legislation.
Out of curiosity, where are you? (I should have geographically qualified my statement.) In New York, the Bay Area and even western Wyoming (in a wealthy enclave), I have never waited more than a week for an appointment.
> fear and outrage was so great that for the first time in decades Republicans took control of the House of Representatives in 1992
Fair enough, will further qualify by last decades.
The bracket I’m speaking of knows European healthcare. They understand it is generally high quality and much cheaper. But being able to demand an MRI or the surgeon of your choice when something goes wrong is a real perk, and the one politicians are talking about when they reference public medicine.
Not the parent, but in Seattle-Tacoma area, I have waited 10 weeks for an ENT, and 12 weeks for PT availability following a car accident (in which case I ended up doing my own PT and bought bands and tools to do so until then).
Anecdotally those wait times seem crazy. The PT one especially. I have 5 different pt choices in walking distance to me that can typically get you in next day or worst case a week lead time if you want a time block that is contended (right before/after normal business hours).
Have you checked if this varies with insurance provider?
This opinion is the opposite of what I’ve heard from people from peer countries who’ve experienced both, not to mention even countries we tend to look down on (there’s an entire industry around even pretty affluent Americans going to Mexico to save money for equivalent treatment). I’d believe it for the 98+th percentile crowd, but I’ve also known people considering going back to Europe because the lower salary is better than all of the out of pocket costs, stress, and risk.
What is perennially interesting is that Republicans (Baby Boomers specifically, in this case) claim to hate "socialized medicine" but every time cuts to Medicare are floated under the guise of "fiscal responsibility" or whatever they're DOA. It's a trite observation at this point they are truly the fuck-you-got-mine generation.
Sadly, one of the only things that _has_ trickled down from their generation is the belief that "socialized medicine" is evil. A maddeningly large percentage of Gen-Xers, Millennials and beyond have fallen for this line of reasoning. The ironic part, in my direct experience, is that a lot of those folks are the ones getting health insurance from the federal/local governments through the military, emergency response positions, sanitation, etc. So, again, got-mine-fuck-yours.
As a counterpoint, I know a number of people in Europe who have been able to take entrepreneurial risks that either aren't realistic or responsible for people in the U.S. who are tied to their jobs for the sake of healthcare, medical/maternity/paternity/etc. leave, etc. One of them recently had a major health crisis that would have devastated an upstart entrepreneur in the U.S. and was actually able to focus on recovering instead of hustling side gigs or taking out predatory loans to ensure he didn't lose his house or his ability to send his kids to daycare. It's been very enlightening to watch play out in real-time.
Existing socialized medicine, that helps them, is OK. New socialized medicine, which might help other people, is not OK. The politics involved here are not complex.
Nevertheless, we still had to sometimes let people go that didn't have an effective place in the team.
I did not find sufficient information in the article to determine if this was a management problem or a personnel issue.
Without quantitative expectations of performance and safety trade-offs, the actual argument being made here is that a doctor can spend infinite time on a single case and never be reprimanded.
There is an obsession that doctors are special and that no rules can apply to them excpet the ones they write themselves. As someone that has had two relatives die due to medical errors, I stopped drinking the cool-aid of God-complex doctors awhile ago.
Woah, hold on there, false dichotomy.
It's NOT a matter of "Infinite amount of time" vs "quantified expectations with reasonable trade-offs".
It's a matter of "a doctor putting in the time to be careful" vs "being pressured to take 2-5 minutes of to make LIFE-CHANGING medical decisions".
At the end of the day Cigna cares about hitting their numbers to squeeze every last drop of profit while the doctors are being forced to live with the possibility of making a grave mistake being rushed at "burger-flipper" (or "call-center") time scales.
I am on the side of the docs for this one.
I am not on either side, but this God worship of doctors in America is sickening.
Dr. Day having put together the framework for IVIG “based on the scientific evidence available at the time” that “saved millions of dollars” such “that Cigna rewarded her with bonuses and stock options” seems to imply she can balance medical efficacy and speed.
Given ProPublica “reproduced the [productivity] scores of 87% of the Cigna doctors listed; the scores of all but one of the rest fell within 1 to 2 percentage points” simply by “multipl[ying] the number of cases…handled by the time Cigna allotted for each type of case, then divid[ing] that total by the hours…worked that month,” and that the productivity score was used to threaten Day with termination, it would seem there is no safety factor being considered.
She had been working at Cigna 15 years. If she was a bad employee, either she changed personality mid-life or Cigna never noticed in the previous decade plus.
It’s a management problem: she was there for 15 years and had a non-entry level position. Whatever she reported was deliberately created by Cigna’s policies – if not, they would have corrected those policies the first time she reported the problem.
You can see the same pattern with the claim about being unaware of “click to close” or the refusal to clarify when their excuse about the dashboards being misunderstood was challenged. If this wasn’t intentional, someone would correct it the first time they saw patients being denied treatment and they’d easily be able to show, for example, employee training & review policies showing the opposite. We’re not talking about McDonald’s here, it would be very uncontroversial to have a policy that their medical doctors need time to get the best outcome for the patient – if that was actually their goal.
Health insurance companies can set the maximum time of review to whatever they want, and if the doctor doesn't decide by then, it gets approved. Doctors should also not be evaluated on % approved vs disapproved, since that provides a perverse incentive.
I'm happy I got what I wanted, but at this point what's their service, rubberstamping requests for money?
Medical care is strange in that the operational staff includes doctors, who will bristle at their expertise and years of schooling culminating into being judged on how many reviews (or appointments) they can churn through.
It's an interesting issue that I sense naturally causes this kind of conflict.
Each special interest group carved out a chunk of taxes and Power, and now they seek to expand through taxation or higher prices/lower quality.
I own a clinic and our most maligned incentives are that medicaid patients have basically free care, so they will somehow find themselves getting more visits than someone who has private insurance is paying out of pocket until deductibles are met and is much more cost conscious.
But their denial lead to more pain, and an appeal takes at least 30 days.
There should be a law that says you are guaranteed continued treatment when your appeal is pending. That way they actually have the incentive to do it properly. Now whether that again is a close and deny... yea, not sure what the solution is there.
"Handle time" (or velocity) is easy to measure, so we measure it. Quality is important, but its hard to measure.
What we choose to measure gets focused on, so handle time (or velocity) ends up taking focus from quality, or customer satisfaction, etc, etc.
> The "click and close" practice was common at Cigna, where doctors would quickly deny coverage requests by simply copying and pasting denial language prepared by nurses, rather than thoroughly reviewing each case.
There are a lot of issues in the medical system but primary care seems to be one of the biggest offenders.
140 years ago the American Medical Association started siphoning resources and clawing power.