Report alleges patients frequently forced to pay out-of-pocket for services that should be covered

Washington, D.C. — House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-WA), Subcommittee on Health Chair Brett Guthrie (R-KY), and Subcommittee on Oversight and Investigations Chair Morgan Griffith (VA), on behalf of the Health and Oversight Subcommittee Republicans, wrote to the President and CEO of The Cigna Group regarding an investigative report by ProPublica.  

In the letter, the members note that Cigna disputes the report as “biased” and “incomplete,” and they ask the insurance company to respond to the allegations that it uses automation and AI technology to deny claims.  

According to the report titled “How Cigna Saves Millions by Having its Doctors Reject Claims Without Reading Them,” which focuses on Cigna’s procedure-to-diagnosis (PXDX) review process:  

• The PXDX review process denies payments for claims indiscriminately, potentially leading to improper denials of coverage for medically necessary tests and procedures.  
• The process automatically categorizes certain claims as “unnecessary” using an algorithm in place of a clinician’s judgement.  
• Patients are then reportedly told that a clinician has decided such claims were not necessary and therefore not covered, despite the clinician having never reviewed individual claims.  
• Only an estimated five percent of policy-holders appeal denials of coverage.  
• By contrast, nearly one-in-five prior authorization denials in Cigna’s Medicare Advantage plans were appealed.  

Why It Matters:  

• 80 percent of Medicare Advantage coverage denials were overturned, suggesting that Cigna’s PXDX review process is leading to patients paying out-of-pocket for medical care that should be covered under their insurance policy contract.  

The Chairs requested Cigna turn over documents related to the PXDX process and answer the following questions by May 30, 2023:  

1. Describe in detail the PXDX review process, including its development, implementation, and ongoing usage.  
2. Identify all insurance plans offered or administered by Cigna whose claims are subject to PXDX review, including, if applicable, Medicare Advantage plans.  
3. Identify all medical directors employed by Cigna who review, submit, or approve coverage denials generated by the PXDX review process, include in your response the medical directors’ work email address, the nature of claims reviewed, and tenure at the company.  
4. Provide the following statistics for plan year 2022 for both commercial and government contracts (broken down by government program):  
5. The number of claims reviewed by the PXDX process;  
6. The number of claims denied under the PXDX process;  
7. The number of claims reviewed and denied by each clinician employed by Cigna who participates in the claim review process;  
8. The number of claims denied by each clinician employed by Cigna and the number of claims that were actually reviewed by such clinicians;  
9. The number of claims denied under the PXDX process that were appealed; and  
10. The number of claims denied under the PXDX process that were appealed and overturned.  

In addition, the letter serves as a request to preserve all existing and future documents related to the PXDX process.  

CLICK HERE to read the full letter.