Dive Brief:
- Cigna is facing a second class action lawsuit over the health insurer’s use of software to automate claims processing.
- The lawsuit filed in Connecticut district court late August alleges Cigna’s “procedure-to-diagnosis” or PxDx software reviewed and denied customer claims in batches without a medical professional reviewing those decisions.
- Cigna faces an almost identical lawsuit in California that was filed earlier this summer. The payer defends the technology as a standard review process similar to those used by other insurers.
Dive Insight:
Cigna has been in the hot seat over its use of automatic claims processing software since earlier this year, after a ProPublica investigation found Cigna physicians used PxDx to automatically reject claims without opening a patient’s file.
The House Energy and Commerce Committee and state regulators are investigating Cigna’s use of the software, and in July two Cigna members in California sued the payer, alleging they were illegally denied payment because of PxDx.
The algorithm works by flagging discrepancies between a diagnosis and what Cigna considers acceptable tests and procedures for that condition. The suits allege the Connecticut-based payer used the technology to deny payment to hundreds or thousands at a time.
That lawsuit — and the new suit filed in Connecticut — both cite ProPublica findings that PxDx was used to reject more than 300,000 requests for payment over two months in 2022. The average time taken to deny each claim was just 1.2 seconds.
The plaintiff in the Connecticut suit alleges she was denied reimbursement for a medically necessary colonoscopy and endoscopy as a result of Cigna “automatically and algorithmically denying claims.”
Insurance laws and regulations in many states require reviews of medical records before payers deny claims for medical reasons. Connecticut statute requires health insurers to conduct a “reasonable investigation based on all available information.”
In response to the new suit, a Cigna spokesperson directed Healthcare Dive to the payer’s previous public statement about the PxDx allegations.
“This copycat suit is baseless,” the spokesperson added. “Based on our research, the claim in the complaint was not subject to Cigna’s PxDx review, and the complaint seems to be based on an article riddled with factual errors and misinformation.”
The suit filed in Connecticut seeks class action status covering every individual nationwide who had claims reviewed using PxDx.
The exact size of that group is unknown but could be significant — currently, the payer provides medical coverage to 19.5 million people in the U.S.
