A new Pro Publica report exposes how Cigna requires its medical directors to review prior authorization denials at breakneck speed, preventing patients from getting critical care. One medical director at Cigna revealed that, as of about five years ago, she was required to review so many coverage denials in a day as to keep her from ensuring patients received appropriate coverage for their care. This is yet another reason why enrolling in a Medicare Advantage plan entails significant risk if you develop a costly condition.
Some states allow health insurance company nurses to decide whether someone in the US should get treatment without oversight by a physician. But, some states do not allow insurers to deny claims without a doctor reviewing them. In those states, a medical director must review the nurses’ decisions; but, health insurers can determine how long their medical directors spend on these reviews.
A few years ago, Cigna began hiring nurses in the Philippines to make coverage determinations. Cigna’s medical directors in the US reviewed their denials. Dr. Debby Day, a Cigna medical director, explains that Cigna was not giving her the requisite time to do so.
According to Dr. Day, the nurses in the Philippines have increasingly been inappropriately denying Cigna enrollees coverage. She refused to rubber stamp the nurses’ denials or “click and close” them as many of her fellow medical directors did.
“Deny, deny, deny. That’s how you hit your numbers,” said Dr. Day, who worked for Cigna until the late spring of 2022. “If you take a breath or think about any of these cases, you’re going to fall behind.”
In response to a Pro Publica query, Cigna claimed that its medical directors were not permitted to click and close nurses’ care denials. But, Cigna shared information about the number of case reviews each medical director was performing—“the productivity dashboard”– with all of them as a way to boost their productivity. The medical directors who performed fewer reviews were considered less productive.
Companies in many industries typically study the efficiency of their workers. But, in health care, speedy reviews can lead to inappropriate denials of critical care or coverage for services.
In January and February 2022, Cigna gave medical directors four minutes to review a prior authorization decision for an expensive treatment. Cigna gave them as little as two minutes to review a request for drug coverage. And, it gave medical directors just four and a half minutes to determine whether a patient should be discharged from hospital.
As has been previously reported, Cigna and other insurers often use an algorithm to reject certain claims collectively. On average, medical directors spend 1.2 seconds on those claims.
Dr. Day spent more time reviewing coverage determinations than most of her peers. She felt that Cigna rewarded those who spent less time reviewing these determinations, without considering the quality of their work.
In response to a question from Pro Publica about incentives to deny claims, Cigna argued that it took less time to approve them, failing to acknowledge that their nurses did the time-consuming work to “justify” denials and that clinicians simply had to click and close.
Dr. Day explained that during the first several years she worked at Cigna, she was able to take the time she needed to review cases appropriately, but that all changed a few years ago. Once Cigna hired nurses in the Philippines to conduct the initial case review, Dr. Day found a lot of mistakes in their case reviews that could lead to inappropriate denials. For example, nurses mistook a patient’s parent for the patient, a patient’s hip for her neck, and a patient’s STD for toenail fungus.
Dr. Day said that Cigna was not focused on her correcting its nurses’ erroneous denials; rather, it was focused on her need to be more efficient. Cigna told her that if she did not review more cases and boost her productivity score, she could be fired. It’s no surprise she left the company.
Here’s more from Just Care:
- OIG finds widespread inappropriate care denials in Medicare Advantage
- Medicare Advantage: Expect lots of care denials
- UnitedHealth’s denials of critical rehab services is under investigation
- Humana sued for inappropriate Medicare Advantage care denials
- Medicare Advantage: Denials increase 56 percent
