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In late 2020, Dr Debby Day said her bosses at Cigna gave her a stark warning. Work faster, or the company might fire her.

That was a problem for Day because she felt her work was too important to be rushed. She was a medical director for the health insurer, a physician with sweeping power to approve or reject requests to pay for critical care like life-saving drugs or complex surgeries.

She had been working at Cigna for nearly 15 years, reviewing cases that nurses had flagged for denial or were unsure about. At Cigna and other insurers, nurses can greenlight payments, but denials have such serious repercussions for patients that many states require that doctors make the final call. In more recent years, though, Day said that the Cigna nurses’ work was getting sloppy. Patient files that nurses working in the Philippines sent to her, she said, increasingly had errors that could lead to wrongful denials if they were not corrected.

Day was, in her own words, persnickety. If a nurse recommended denying coverage for a cancer patient or a sick baby, she wanted to be certain it was the right thing to do. So Day said she researched guidelines, read medical studies, and scrutinized patient medical records to come to the best decision. This took time. She was clearing fewer cases than many of her peers.

Some of her colleagues quickly denied requests to keep pace, she said. All a Cigna doctor had to do was cut and paste the denial language that the nurse had prepared and quickly move on to the next case, Day said. This was so common, she and another former medical director said, that people inside Cigna had a term for these kinds of speedy decisions: “click and close.”

“Deny, deny, deny. That’s how you hit your numbers,” said Day, who worked for Cigna until the late spring of 2022. “If you take a breath or think about any of these cases, you’re going to fall behind.”