Medical directors adjudicating claims are supposed to examine patient records, review coverage policies, and use their expertise to approve or deny claims. But at Cigna, they spend only 1.2 seconds on each case and instantly reject millions of claims without even opening the file.
This unfair review process, known as PXDX, is designed to boost profits by reducing claims processing costs, denying coverage, and avoiding payment of health care claims. The volume is staggering. According to a ProPublica exposé, “Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method.”
One former executive describes PXDX as “…a system built to deny claims.” Another, who helped conceive the program, questioned at the time whether such speedy denials satisfied the law or fell into a gray zone. “We sent the idea to legal, and they sent it back saying it was OK.”
It may be legal, but it’s certainly not ethical. The practice leaves patients with unexpected bills and encourages health care avoidance for services that should be covered by any decent employee health plan.
Ironically, Cigna has stated that its PXDX system does not prevent a patient from receiving care — it only decides when the insurer won’t pay: “Reviews occur after the service has been provided to the patient and does not result in any denials of care.”
Employers can circumvent this insanity by avoiding monopoly insurance carriers that prioritize profits over people. The ideal solution is a self-funded plan from a modern health plan plan administrator. Fair Market Payment™ (FMP), which is offered exclusively by Vitori Health, establishes fair and acceptable claim payments and eliminates provider friction that creates balance billing problems for plan members.
With a less costly, more compassionate health plan, employers can realize significant savings and reduce fiduciary risks while improving employee health and other benefits.
