Cigna's PxDx System: A Controversial Path to Profit or Prudent Healthcare Management?
Cigna, one of the giants in the insurance industry, is once again facing scrutiny and legal challenges over its use of the PxDx automated system. The system is designed to identify discrepancies between medical diagnoses and acceptable tests and procedures, purportedly saving the company billions. However, the question arises, is this automated approach fair, ethical, or even legal?
The PxDx System: Streamlining Claims Processing
The PxDx system is an automated tool that screens claims for medical treatments. It was introduced by Cigna as a way to reduce the cost associated with manually reviewing all claims, particularly low-dollar claims that can be financially burdensome to assess individually. In essence, PxDx automatically turns down payments for treatments that don't align with predetermined parameters. The efficiency of this system is evident, with one Cigna doctor stating, "We literally click and submit. It takes all of 10 seconds to do 50 at a time."
Preventing Unnecessary or Harmful Care
Cigna argues that PxDx is designed to prevent claims for care they consider unneeded or even potentially harmful to patients. From the company's perspective, this approach not only benefits them financially but also safeguards patients from potentially inappropriate treatments.
The Legal and Ethical Gray Area
The crux of the matter lies in the legality and ethics of such a system. According to the developer of PxDx, it is intended to operate within the confines of the law. However, as is often the case with emerging technologies, the lines are blurry. A Cigna Executive admitted, "We thought it might fall into a legal gray zone. We sent the idea to legal, and they sent it back saying it was OK."Though, is is also important to remember that former Cigna executive Ron Howrigon described PxDx as "a system built to deny claims."
The Appeal Dilemma
One of the most significant concerns is that reviews occur after the service has been provided to the patient and often do not result in denials of care. This poses a significant problem as patients may still receive the treatment they need, but the insurance claim is denied. Many patients, faced with the hassle and fear of bills going to collections, simply choose to pay the bill out of their pocket. For insurance carriers like Cigna, this can translate into increased profits at the expense of their customers.
The troubling aspect is whether Cigna is directly targeting low-dollar claims with the intent to force patients to pay their bills out-of-pocket. In a corporate document, Cigna even stated in writing that they expected only 5% of people would appeal a denial resulting from a PxDx review.
The ethical and legal implications of Cigna's PxDx system raise important questions about the role of automation in insurance claims processing. While streamlining operations and reducing unnecessary care is undoubtedly a worthy goal, it should not come at the expense of transparency, fairness, or the financial burden of the patient. The debate on whether insurance carriers should be allowed to use automated systems to cut costs and reduce unnecessary treatment is an ongoing one, reflecting the tension between corporate interests and the welfare of policyholders. Ultimately, the balance between cost-cutting and ethical responsibility is a critical consideration for the insurance industry and those it serves.