Cigna sued for using software to deny healthcare insurance claims Cigna has been sued in California based on allegations the US healthcare insurer unlawfully reviewed insurance claims using automated systems rather than relying on humans. Under America's healthcare system, such as it is, a medical patient typically sees a doctor and receives diagnosis and possibly treatment. The physician ( …
All they did was auto-approve some standard claims if they matched certain specific parameters, while reviewing (NOT auto-denying) the ones that didn't. I have no love for Cigna or other insurance companies, having spent far too many hours getting claims fixed (i.e. reprocessed after being wrongly denied), but in this narrow case they seem to be doing things reasonably.
Now, that statement about "nobody was denied service because our claims processing is after the fact" is sophistry. If you're denied for a claim, you owe the doctor whatever they feel like charging you, and you won't be going back because of the cost. That's still effectively denying service.
> simple sorting technology that has been used for more than a decade – it matches up codes, and does not involve algorithms
Oooof!
But then I read on:
> perhaps not what people in general think when they hear the word "algorithm" in this era of machine learning and recommendation engines.
Recommendation engines - those simple sorting routines that literally come up with "people who bought secateurs also bought bandages"!
Five years after Hannah Fry's book, it looked like Joe Public was understanding the word. Now some prat of a lawyer is trying to argue against its meaning. Aaaarghhh.
What cruel god is this, that plays with us so?
I'm pretty sure that my preschooler having to go to the hospital because of a lack of ability to breathe decently doesn't have anything to do with my or my neighbors' bad habits. (No smokers in the house, and outside air is quite clean.)
Sometimes medical events happen without anyone being at fault.
The really sad thing about this reply is the inability to look ahead[1] - and consider how insurance basically works (well, how it was supposed to work before actuaries got too involved ...) and how that compares to how a funded medical system actually works.
The being a total dick and blaming other people for *all* of their medical problems is just the icing on the cake that makes you a fully rounded personality.
[1] wait until you see your insurance premiums as you age and/or develop an unfortunate condition of your own.
Every functional piece of code consists of implementation of one or more algorithms, so software that "does not involve algorithms" can not exist. The origin of this error is the same sloppy thinking that has restricted "crypto" to the sole meaning of cryptocurrencies. If this process of verbal reductionism persists, eventually we won't be able to discuss anything except the latest technological flummeries.
That would be too obvious, and might be too much for our bought and paid for politicians to not do something about. I figure it is something more like:
[code[
#!/bin/bash
if [ $((1 + $RANDOM % 100)) -gt 70 ]; then
CLAIM_STATUS=denied
else
CLAIM_STATUS=approved
fi
[/code]
BTW, I am a "customer" of Cigna and my healthcare is a clusterfuck, Everything about this is true.
Under our system a doctor will diagnose a condition and recommend a treatment. The insurance company then has to preapprove the recommendation. Its this step that's prone to automatic denial. If you go to treatment without permission then the insurer won't pay for it.
I think that you're suffering the same process in the UK, the difference being that the applications get lost in some bureaucratic maze rather than being outright denied.
I've had US health care my entire life, under various types of plans – "conventional" (which isn't anymore, and hasn't been for a while), HMO, PPO ... – and none of them have worked the way you describe. With HMOs it is often required to get a referral for out-of-network non-emergency care. All the PPOs I've had have approved payment after treatment, not before; there hasn't been any pre-approvement process.
"sometimes the preauthorization is needed for emergency care"
It is therefore vitally important to have your insurance details on the lock screen of your phone (and on speed dial if you are lucky enough to catch you before the timeout licks the phone).
Dystopia? No, dat 'topia, dis topiary.
(The AC you replied to)
They administered the emergency care well before asking for insurance. The care had to be “preauthorized”, which in medical jargon (doublespeak?) means the physician has to provide documentation showing why the care is medically necessary, before the insurance will cover it. Being emergency care, the “preauthorization” was performed after the care was administered, weeks later, in fact, even after the claim was “denied”. (Another bit of doublespeak, in many cases “denied” just means “we want some info first”.)
CIGNX denies claims based on if they think the patient is "too old to live" or has a likelihood of becoming MORE ill and thus making more claims. Deny claim, wait for grandma to snuff it and go quiet, hoping no-one realizes she was insured and the medication would have prolonged or saved her life.
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