Subtitles section Play video Print subtitles S DENY CLAIMS, AN APPEAL IS NOT LIKELY. FEDERAL DATA SHOWS COMPANIES ISSUED 49 MILLION DENIALS IN '21. CUSTOMERS APPEALED .2 OF 1% OF THEM. WHILE SOME DENIALS COME WITH SPECIFICS, MOST EXPLANATIONS ARE VAGUE. ALLY EXPLORES HOW ONE MAJOR COMPANY IS USING AI TO ASSESS AND OFTEN DENY CLAIMS IN BULK. REPORTER: INVESTIGATIVE JOURNALIST AT PRO-PUBLIC A FOUND CIGNA USES AN AUTOMATED SYSTEM TO INSTANTLY REJECT CLAIMS ON MEDICAL GROUNDS WITHOUT OPENING THE CUSTOMER FILE. SUMMER ACCUSING IT OF USING THE SYSTEM TO HELP CUT COST, WHICH CIGNA DENIES. RYAN MILLER WORKED ON THIS STORY, MAIA, THANK YOU FOR JOINING US. EXPLAIN HOW THE SYSTEM WORKS. >> WHEN YOU GO TO A DOCTOR OR SEE YOUR PROVIDER, THEY WILL SEND IN A CLAIM TO YOUR HEALTH INSURANCE PLAN. THEY WILL LIST THE DIAGNOSIS THEY THINK YOU HAVE AND TESTS OR PROCEDURES THEY WANT TO RUN. THERE IS A PROCESS DEVELOPED AT CIGNA A DECADE AGO IN WHICH THEY CREATED THIS CODE, COMPUTER CODE, ALGORITHM, THAT SAYS WE WILL APPROVE THEM IF THEY MATCH CERTAIN CONDITIONS BUT IF THEY DON'T MATCH ANOTHER CONDITION, LET'S SAY A DIAGNOSIS, THEY DON'T THINK IS WORTHY OF THAT TREATMENT, THEN IT WILL BE SENT TO THE DESK OF A MEDICAL DIRECTOR, WHICH IS A COMPANY DOCTOR, AND THAT DR. WILL BE ABLE TO QUICKLY SIGN OFF ON REJECTING THAT CLAIM AND SAYING WE ARE NOT GOING TO COVER IT. LAST YEAR THAT HAPPENED IN UNDER TWO SECONDS. THESE MEDICAL DIRECTORS WERE ESSENTIALLY SAYING FOR 50 PATIENTS AT A TIME, THEY WOULDN'T EVEN OPEN A FILE, BUT THEY WERE SIGNING THEIR NAME OFTEN SAYING, ACTUALLY THIS CLAIM IS NOT MEDICALLY NECESSARY AND SO WE ARE NOT GOING TO COVER IT. >> I WANT TO READ FROM A STATEMENT CIGNA PROVIDED. THEY SAY THIS AUTOMATED PROGRESS "ALLOWS US TO CLAIM QUICKLY AND ALLOWS DIRECTORS TIME TO LOOK AT MORE COMPLEX REVIEWS." IT ALSO SAYS "EVEN A DENIAL SHOULD NOT RESULT IN OUT-OF-POCKET COSTS FOR PATIENTS WHO ARE USING IN NETWORK FIGHTERS -- IN NETWORK PROVIDERS." >> ON THE FIRST STATEMENT, IT'S TRUE SOME OF THE CLAIMS THAT ARE PROCESSED THROUGH THE SYSTEM, WHICH IS CALLED PXDX, IF THEY MATCH DIAGNOSES AND TREATMENTS ON THE LIST, IF THE CODE SEES THERE IS A MATCH, THEY WILL BE AUTOMATICALLY APPROVED. HOWEVER, THERE IS ABOUT TO THEM THAT AUTOMATICALLY DENIED. THAT IS WHAT WE ARE FOCUSING ON, THE BATCH OF CLAIMS WHICH WE FOUND, IN TWO MONTHS LAST YEAR EXCEEDED 300,000 CLAIMS. NOT AN INSIGNIFICANT AMOUNT. TO THE SECOND POINT ABOUT THIS SHOULD NOT RESULT IN ANY OUT-OF-POCKET COSTS FOR PATIENTS. UNFORTUNATELY THE REALITY IS, OFTENTIMES WHEN WE GO TO A DOCTOR, NURSE OR PROVIDER, WE OFTEN HAVE TO SIGN OFF ON A FORM AND IN THAT FORM WE ARE SAYING, WE WILL TAKE CHRISTMAS ABILITY FINANCIALLY FOR THIS -- WE WILL TAKE RESPONSIBILITY FINANCIALLY FOR THIS, SO IT OFTEN GETS SHUNTED ONTO THE PATIENT. >> WHAT KIND OF TREATMENTS ARE TALKING ABOUT THAT ARE GETTING ROUTINELY DENIED? >> UNFORTUNATELY, WE WERE LOOKING FOR A COMPREHENSIVE LIST OF THESE CLAIMS THAT PROCESSED THROUGH THE SYSTEM. WE KNOW NOT ALL OF THE CLAIMS CIGNA HAS ENDS UP GOING THROUGH THE SYSTEM BUT OF THOSE THAT DO WE LEARNED VITAMIN D TESTING IS LABELED AS PART OF THE SYSTEM. AUTONOMIC NERVOUS SYSTEM TESTING, TO TEST WHETHER YOUR NERVES ARE WORKING WELL -- OFTENTIMES IF YOU HAVE DIABETES OR OTHER AUTOIMMUNE DISEASE, YOU CAN HAVE SOME NERVE DAMAGE IN YOUR FINGERS AND TOES. TESTING TO FIGURE THAT OUT AMONG OTHER CONDITIONS, UNFORTUNATELY, WE COULD NOT FIND A COMPREHENSIVE LIST OF ALL THE DIFFERENT PROCEDURES THAT ARE TAGGED FOR THE SYSTEM BUT THOSE WERE TO THAT WE WERE ABLE TO CONCLUDE. >> CIGNA AND ALL INSURERS IN CLAIMS DENIALS ISSUES WILL SAY THERE IS ALWAYS THE EEL PROCESS -- THE APPEAL PROCESS. WHAT DOES THAT LOOK LIKE IN REALITY? >> ONE IN SEVEN CLAIMS ARE DENIED ACROSS THE COUNTRY. HEALTH INSURANCE CLAIMS. IT AFFECTS A LOT OF PEOPLE. ONE STUDY FOUND .1% OF ALL PEOPLE WHO EXPERIENCE DENIALS ACTUALLY TOOK IT TO DO A FORMAL APPEAL. WHEN YOU ARE GOING ABOUT YOUR DAY TODAY, MAYBE YOU ARE FACING ILLNESS, A DISEASE, A CHRONIC DISEASE, IT'S HARD TO FIND THE TIME AND WHEREWITHAL TO FIGURE OUT HOW TO APPEAL CLAIMS. REALITY IS, VERY FEW PEOPLE DO. WE FOUND THROUGH REPORTING, CIGNA HAD A PRESENTATION IN WHICH THEY WERE PUTTING FORWARD THE IDEA TO PUT ON AUTONOMIC NERVOUS TESTING THROUGH THE SYSTEM AND IN THE COST-BENEFIT ANALYSIS ASSESSING WHETHER TO DO THIS, THEY ASSUMED 5% OF PATIENTS WOULD END UP APPEALING THIS AND THAT WAS PART OF THE CALCULATION OF WHETHER TO PUT THIS TEST INTO THIS PROGRAM OR TO LEAVE IT OUT. REPORTER: CIGNA IS NOT THE ONLY INSURER WITH AN AUTOMATED SYSTEM LIKE THIS. DO YOU HAVE A SENSE OF HOW PREVALENT AUTOMATED SYSTEMS ARE RIGHT NOW IN THE HEALTH SYSTEM WRIT LARGE? >> IT APPEARS TO BE PREVALENT. INSURANCE COMPANIES DEAL WITH MILLIONS OF CLAIMS. IN ORDER TO STAY ON TOP OF THIS AND MAINTAIN EFFICIENCY WHICH IS WHAT THEY SAID, THEY HAVE TURNED TO ALGORITHMS AND COMPUTER PROGRAMS TO PROCESS CLAIMS AS QUICKLY AND EFFICIENTLY AS POSSIBLE, IS WHAT THEY SAY. IT SEEMS THIS KIND OF TECHNOLOGY IS PREVALENT ACROSS THE INDUSTRY, ALTHOUGH WE ARE STILL REPORTING, FOR OTHER INSURANCE PLANS, WE ARE TRYING TO CONFIRM THAT. IT SEEMS PRETTY PERVASIVE. REPORTER: THERE WAS A ROBUST DEBATE HAPPENING ABOUT THE HAZARDS OF USING AI. WHERE DOES THIS CONVERSATION FIT INTO THE BROADER DEBATE ABOUT UTILITY AND HAZARDS OF USING ARTIFICIAL INTELLIGENCE? >> GREAT QUESTION AND ONE WE ARE POSING TO REGULATORS RIGHT NOW. THE FORMER INSURANCE COMMISSIONER OF CALIFORNIA, DAVE JONES, TOLD US IN THE STATUTES, YOU NEED TO HAVE A THOROUGH, FAIR AND OBJECTIVE ASSESSMENT OF PATIENT CLAIMS AND IF A MEDICAL DIRECTOR OR COMPANY DOCTOR FOR AN INSURANCE PLAN IS REALLY LOOKING AT A CLAIM IN LESS THAN TWO SECONDS ON AVERAGE, CAN YOU ACHIEVE THAT RESULT? I WOULD POSE THAT QUESTION TO THE LAWMAKERS, REGULATORS, TO SEE WHERE THEY WOULD STAND ON THAT. >> MY ML OR, THANK YOU FOR YOUR TIME. >> THANKS FOR HAVING ME. ♪
B1 US insurance system automated claim appeal health insurance How algorithms are being used to deny health insurance claims in bulk 9 0 林宜悉 posted on 2023/04/04 More Share Save Report Video vocabulary