October 20, 2023

Plaintiff drops out of lawsuit accusing Cigna of improperly rejecting claims

A lawsuit accusing Cigna of improperly rejecting medical claims was refiled this week – minus one of the two California plaintiffs.

Initially filed in July, the federal lawsuit alleges that Cigna used a computer algorithm to automatically reject hundreds of thousands of patient claims without examining them individually as required by California law.

It was filed as a class-action lawsuit by plaintiffs Suzanne Kisting-Leung and Ayesha Smiley. An amended complaint was filed Monday listing Kisting-Leung as the sole plaintiff.

Cigna Healthcare released a statement that called the lawsuit “baseless and seems to erroneously assume that every claim goes through Cigna’s ‘Procedure to Diagnosis’ (also knows as “PxDx”) review, when in reality, only a small subset of services do. Based on our research, the claims in the complaint were not subject to Cigna’s PxDx review, and in fact, one of the original plaintiffs was not even a Cigna customer.

“To be clear: patients are not denied care through PxDx because the review takes place only after they receive treatment, and most do not experience any additional costs even if a claim is denied. Procedure to Diagnosis is a simple process that helps accelerate payments to clinicians for common, relatively low-cost tests and treatments, and it is not powered by AI or an algorithm. This is an industry-standard review which is similar to processes that have been used by CMS and our peers for many, many years.”

Second lawsuit on algorithm

Cigna was recently hit with another lawsuit in Connecticut over its use of the computer algorithm to deny claims. Plaintiff Paige Van Pelt makes similar claims as Kisting-Leung over Cigna’s use of an algorithm called PXDX, shorthand for ”procedure-to-diagnosis,” to identify whether claims met certain requirements.

The program spent an average of just 1.2 seconds on each review, according to the lawsuits. Large numbers of claims were then sent on to doctors who signed off on the denials, the lawsuits say. Cigna medical directors reportedly automatically denied, without review, over 300,000 requests for payments, the lawsuit claims.

“Cigna has leveraged its sophisticated infrastructure and automated intelligence capabilities to systematically defraud its consumers by denying medically necessary claims en masse without appropriate physician review,” the Van Pelt lawsuit states. “PxDx allows Cigna medical directors to automatically deny a claim purportedly on medical grounds without making a medically necessary determination or even opening the patient file, leaving patients with unexpected bills that should have been covered and paid.”

Connecticut-based Cigna has 18 million U.S. members. Van Pelt, of Aitkin, Minn., was enrolled in a self-funded Cigna Plan throughout 2018.

Cancer history

Van Pelt has Lynch Syndrome — a type of inherited cancer syndrome associated with a genetic predisposition to different cancer types, her lawsuit states. In order to prevent cancerous growths, she is required to have a colonoscopy once every one-to-two years.

“In 2018, Cigna automatically denied coverage for her colonoscopy and endoscopy, because the clinic coded it as diagnostic instead of preventative,” the lawsuit reads. “As a result, Plaintiff was charged $3,200 which has since been sent to collections.”

In another case, Cigna recently reached a settlement with the United States over claims it overcharged the government’s Medicare Advantage program by making it appear patients were more ill than they actually were.

The settlement includes a payment of about $172 million by Cigna.

InsuranceNewsNet Senior Editor John Hilton covered business and other beats in more than 20 years of daily journalism. John may be reached at john.hilton@innfeedback.com. Follow him on Twitter @INNJohnH.

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