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A Doctor at Cigna Said Her Bosses Pressured Her to Review Patients’ Cases Too Quickly.
Posted on 5/6/24 at 5:10 am
Posted on 5/6/24 at 5:10 am
LINK
In late 2020, Dr Debby Day said her bosses at Cigna gave her a stark warning. Work faster, or the company might fire her.
That was a problem for Day because she felt her work was too important to be rushed. She was a medical director for the health insurer, a physician with sweeping power to approve or reject requests to pay for critical care like life-saving drugs or complex surgeries.
She had been working at Cigna for nearly 15 years, reviewing cases that nurses had flagged for denial or were unsure about. At Cigna and other insurers, nurses can greenlight payments, but denials have such serious repercussions for patients that many states require that doctors make the final call. In more recent years, though, Day said that the Cigna nurses’ work was getting sloppy. Patient files that nurses working in the Philippines sent to her, she said, increasingly had errors that could lead to wrongful denials if they were not corrected.
Day was, in her own words, persnickety. If a nurse recommended denying coverage for a cancer patient or a sick baby, she wanted to be certain it was the right thing to do. So Day said she researched guidelines, read medical studies, and scrutinized patient medical records to come to the best decision. This took time. She was clearing fewer cases than many of her peers.
Some of her colleagues quickly denied requests to keep pace, she said. All a Cigna doctor had to do was cut and paste the denial language that the nurse had prepared and quickly move on to the next case, Day said. This was so common, she and another former medical director said, that people inside Cigna had a term for these kinds of speedy decisions: “click and close.”
“Deny, deny, deny. That’s how you hit your numbers,” said 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 late 2020, Dr Debby Day said her bosses at Cigna gave her a stark warning. Work faster, or the company might fire her.
That was a problem for Day because she felt her work was too important to be rushed. She was a medical director for the health insurer, a physician with sweeping power to approve or reject requests to pay for critical care like life-saving drugs or complex surgeries.
She had been working at Cigna for nearly 15 years, reviewing cases that nurses had flagged for denial or were unsure about. At Cigna and other insurers, nurses can greenlight payments, but denials have such serious repercussions for patients that many states require that doctors make the final call. In more recent years, though, Day said that the Cigna nurses’ work was getting sloppy. Patient files that nurses working in the Philippines sent to her, she said, increasingly had errors that could lead to wrongful denials if they were not corrected.
Day was, in her own words, persnickety. If a nurse recommended denying coverage for a cancer patient or a sick baby, she wanted to be certain it was the right thing to do. So Day said she researched guidelines, read medical studies, and scrutinized patient medical records to come to the best decision. This took time. She was clearing fewer cases than many of her peers.
Some of her colleagues quickly denied requests to keep pace, she said. All a Cigna doctor had to do was cut and paste the denial language that the nurse had prepared and quickly move on to the next case, Day said. This was so common, she and another former medical director said, that people inside Cigna had a term for these kinds of speedy decisions: “click and close.”
“Deny, deny, deny. That’s how you hit your numbers,” said 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.”
Posted on 5/6/24 at 5:18 am to Eurocat
Not fast enough for diversity
Posted on 5/6/24 at 5:34 am to Eurocat
This has been the case for years. Insurance-paid physicians with little-to-no direct patient interaction denying coverage for medication or procedures. Given who is paying them, I can’t possibly imagine there could be a conflict of interest there.
Posted on 5/6/24 at 5:39 am to Eurocat
quote:
Eurocat
I’m sure what you posted is completely accurate and not biased in the least
This post was edited on 5/6/24 at 5:40 am
Posted on 5/6/24 at 5:50 am to Eurocat
Insurance companies can be a Bain to societies. The only time an insurance should be allowed to deny treatment is if they believe it to be fraudulent.
Posted on 5/6/24 at 6:14 am to TigerFanatic99
quote:
insurance should be allowed to deny treatment
It's not denying treatment, only coverage. A patient always has the option to receive and pay for treatment that insurance doesnt cover.
Posted on 5/6/24 at 6:32 am to LSUfan4444
quote:
It's not denying treatment, only coverage. A patient always has the option to receive and pay for treatment that insurance doesnt cover.
Do hospitals give the exact price for treatment?
Have you ever tried to get an absolute price on something at a medical facility.
Posted on 5/6/24 at 6:32 am to LSUfan4444
quote:
A patient always has the option to receive and pay for treatment that insurance doesnt cover.
For many it is the only way to get treatment. Not everyone can pay.
Posted on 5/6/24 at 6:35 am to TigerFanatic99
quote:
Insurance companies can be a Bain to societies. The only time an insurance should be allowed to deny treatment is if they believe it to be fraudulent.
A guy gets hurt at work, twists an ankle pretty bad. Goes to the hospital to get it checked out, make sure it isn't broken. Diagnosed as a bad sprain. Doctor writes him a script for crutches, a walking boot, Viagra for his ED, and a splint for his finger that has been giving him problems after injuring it at home. The hospital submits the bills to his work comp insurance company and the Viagra and the finger splint are denied. You think that should be approved? It's not fraud, but absolutely should be denied.
Posted on 5/6/24 at 6:49 am to Eurocat
No surprise.
Humana launched a computer program to bulk-deny claims.
Humana launched a computer program to bulk-deny claims.
Posted on 5/6/24 at 6:52 am to TigerFanatic99
Fraud, unnecessary treatment, and valid treatment are a fine line… so you have to hire Doctors to make a call which is what Cigna did here. Problem seems to be likely they prioritized speed over quality.
This post was edited on 5/6/24 at 6:58 am
Posted on 5/6/24 at 6:54 am to Eurocat
So hypothetically, insurance companies are supposed to allow the folks who review cases as much time to review cases as the reviewers personally feel is necessary?
None of us here (from reading a biased article) know if this is valid or not.
It’s why I enjoy having healthcare professionals in my family and as friends.
None of us here (from reading a biased article) know if this is valid or not.
It’s why I enjoy having healthcare professionals in my family and as friends.
Posted on 5/6/24 at 7:05 am to soccerfüt
Cigna isn't look for the truth they want a rubber stamp denial.
Posted on 5/6/24 at 7:08 am to LSUfan4444
Insurance should cover whatever a physician or allied health professional recommends. Period. They should have no right to deny. But it’s not medical insurance anymore, it’s managed care.
Posted on 5/6/24 at 7:11 am to mahdragonz
quote:
exact price
quote:
absolute price
Not exactly sure what you're asking. Are you asking about getting their reimbursement price or the cash price as a patient?
quote:
Insurance should cover whatever a physician or allied health professional recommends. Period
Then why don't the physicians provide coverage? Oh yeah, this is why.
LINK
LINK
There is a reason that the health outcomes vs cost in the US is so terrible.
This post was edited on 5/6/24 at 7:13 am
Posted on 5/6/24 at 7:12 am to Bestbank Tiger
Several of them are getting sued in class actions for using AI in denying claims. The average time for human review per claims for one of the networks is like 1.2 seconds.
Posted on 5/6/24 at 7:15 am to SouthEndzoneTiger
quote:
ou think that should be approved?
People in this country have a very low understanding of how the healthcare system works, why it's broken and not much desire to actually fix it. So long as someone else pays for something that isn't working, they like that more than something which actually works.
Posted on 5/6/24 at 7:15 am to soccerfüt
quote:
None of us here (from reading a biased article) know if this is valid or not.
Don’t know about the length of time part, but the insurance physician regularly declining necessary procedures occurs regularly (my wife deals with them often).
Posted on 5/6/24 at 7:18 am to whodatdude
quote:
the insurance physician regularly declining necessary procedures occurs regularly
Insurance companies review these requests against standard criteria. There are times that requests do not fall within that determined criteria which requires a medical director's review and that's what is being described in the article. When it's reviewed there is alot that is factored in and it differs from patient to patient. Are there cases denied that should have been approved, sure. There are also plenty plenty plenty plenty plenty plenty more that are approved and offer zero improvement or improved health outcomes.
The US healthcare system and the reimbursement system used isthe most wasteful healthcare system in the world.
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