Click and close

The way to make money in America’s private health insurance industry is to deny coverage. There’s no question about that. The question is whether the denials are valid. According to one long-time doc, industry is valorizing speed over accuracy.

“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.”

This is a policy at Cigna:

“ProPublica and The Capitol Forum examined Cigna’s productivity dashboards for medical directors from January and February 2022. These spreadsheets tallied the number of cases each medical director handled. Cigna gave each task a “handle time,” which the company said was the average amount of time it took its medical directors to issue a decision.

 

“Day and others said the number was something different: the maximum amount of time they should spend on a case. Insurers often require approval in advance for expensive procedures or medicines, a process known as prior authorization. The early 2022 dashboards listed a handle time of four minutes for a prior authorization. The bulk of drug requests were to be decided in two to five minutes. Hospital discharge decisions were supposed to take four and a half minutes.”

This practice has been described as “click and close.” And there’s more:

 

“As ProPublica and The Capitol Forum reported last year, Cigna built a computer program that allowed its medical directors to deny certain claims in bulk. The insurer’s doctors spent an average of just 1.2 seconds on each of those cases. Cigna at the time said the review system was created to speed up approval of claims for certain routine screenings; the company later posted a rebuttal to the story. A congressional committee and the Department of Labor launched inquiries into this Cigna program. A spokesperson for Rep. Cathy McMorris Rodgers, the chair of the congressional committee, said Rodgers continues to monitor the situation after Cigna shared some details about its process. The Labor Department is still examining such practices.”

I’m sure Trump’s Labor Department will drop this.

Cigna claims Dr. Day is just a disgruntled former employee. But it isn’t just Dr. Day:

“But another doctor who had worked at Cigna also said that denying a request for payment was far quicker than approving one since the nurses served up language that could be used to justify the denial. That former Cigna medical director said, “Sometimes you just have to accept the nurse and click and close if you had too much work.” (That doctor asked not to be named because they feared repercussions if they commented publicly.)”

https://www.propublica.org/article/cigna-medical-director-doctor-patient-preapproval-denials-insurance?utm_campaign=propublica-sprout&utm_content=1737251400&utm_medium=social&utm_source=facebook&fbclid=IwY2xjawH7LPVleHRuA2FlbQIxMQABHcxcp8ywpKTXilTlnRJN81tflBwqHK0EY76lKdgZq-dG2k-W2ZcJ6J_T-g_aem_pqZgzsPJSBMLr46k_syAuQ