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Started By
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A Doctor at Cigna Said Her Bosses Pressured Her to Review Patients’ Cases Too Quickly.
Posted on 5/6/24 at 5:10 am
Posted on 5/6/24 at 5:10 am
LINK
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.”
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.”
Posted on 5/6/24 at 5:18 am to Eurocat
Not fast enough for diversity
Posted on 5/6/24 at 5:34 am to Eurocat
This has been the case for years. Insurance-paid physicians with little-to-no direct patient interaction denying coverage for medication or procedures. Given who is paying them, I can’t possibly imagine there could be a conflict of interest there.
Posted on 5/6/24 at 5:39 am to Eurocat
quote:
Eurocat
I’m sure what you posted is completely accurate and not biased in the least
This post was edited on 5/6/24 at 5:40 am
Posted on 5/6/24 at 5:50 am to Eurocat
Insurance companies can be a Bain to societies. The only time an insurance should be allowed to deny treatment is if they believe it to be fraudulent.
Posted on 5/6/24 at 6:49 am to Eurocat
No surprise.
Humana launched a computer program to bulk-deny claims.
Humana launched a computer program to bulk-deny claims.
Posted on 5/6/24 at 6:54 am to Eurocat
So hypothetically, insurance companies are supposed to allow the folks who review cases as much time to review cases as the reviewers personally feel is necessary?
None of us here (from reading a biased article) know if this is valid or not.
It’s why I enjoy having healthcare professionals in my family and as friends.
None of us here (from reading a biased article) know if this is valid or not.
It’s why I enjoy having healthcare professionals in my family and as friends.
Posted on 5/6/24 at 7:19 am to Eurocat
quote:
In late 2020
Hmmm
Wonder what was happening then
Posted on 5/6/24 at 7:21 am to Eurocat
quote:
reviewing cases that nurses had flagged for denial or were unsure about
Problem number 1 here.
Posted on 5/6/24 at 7:23 am to Eurocat
Can’t speak for other areas but while insurances can be a real pain in the arse, Cigna might be one of the worst. Their reimbursement rates are so low in our area that a ton of providers don’t even bother credentialing with them.
ETA: Unfortunately they’re going to merge with Humana. That’s going to be a shitshow.
ETA: Unfortunately they’re going to merge with Humana. That’s going to be a shitshow.
This post was edited on 5/6/24 at 7:26 am
Posted on 5/6/24 at 7:34 am to Eurocat
This article actually makes it seem nurses and doctors review every claim was is completely untrue.
They hire kids off the street to check claims and send denials. A nurse/DR probably doesn’t see it til the decision is appealed.
Like stated already some insurances are reverting to AI and programs to auto deny. Insurances are not your friend
They hire kids off the street to check claims and send denials. A nurse/DR probably doesn’t see it til the decision is appealed.
Like stated already some insurances are reverting to AI and programs to auto deny. Insurances are not your friend
Posted on 5/6/24 at 7:34 am to Eurocat
This is why I tell all my patients to make insurance give multiple refusals before giving up
Posted on 5/6/24 at 7:37 am to Eurocat
quote:
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.”
I know we like to all pile on tort lawyers for their contributions to the problem of insurance premiums. And they deserve it. But just remember that this happens at all insurers for all types of insurance claims. They play a role also. Rainmaker is, although obviously dramatic for movie purposes, instructive on this.
This post was edited on 5/6/24 at 7:40 am
Posted on 5/6/24 at 7:38 am to Eurocat
Sounds like the hospital version of Rainmaker by John Grisham where the insurance company in question was denying all claims initially and then paying out only if they had a serious one and fought for it.
Posted on 5/6/24 at 8:10 am to Eurocat
quote:Found the problem. Possibly the most oversaturated nursing labor market in the world.
nurses working in the Philippines
This post was edited on 5/6/24 at 8:17 am
Posted on 5/6/24 at 8:20 am to Eurocat
People use arguments like this as a reason private insurance is better than single payer. The corporate/government partnership insurance system we have now is no better for people.
Posted on 5/6/24 at 8:38 am to Eurocat
quote:
Deny, deny, deny.
Great Benefit
Posted on 5/6/24 at 8:42 am to Eurocat
So denying coverage is essentially up to dancing tiktok nurses??
Posted on 5/6/24 at 9:10 am to Eurocat
That’s all BS. Perfectly set up for the “big insurance companies are mean! I want more government involvement in health care!” crowd at election time. And since when do doctors at insurance companies review cases? They don’t. Those are some by regular employees. And pricing and payouts are already decided. They don’t review them one by one and say pay this, don’t pay that, let that person die. That’s the socialist medicine model, not ours. Totally fake article.
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