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.

♪