A Doctor at Cigna Said Her Bosses Pressured Her to Review Patients’ Cases Too Quickly

I first caught up with this article on MedPage Today, “Doc Blows Whistle on Cigna.” I also read the ProPublic report. Both are reporting on denial of claims before and after treatment and the productivity of claims reviewers. Additionally, the report discusses the use of labor (nurses, etc.) outside of the US to evaluate claims and their errors. All of these attempts are examples of what is going on to cuts costs by reducing the time to decide on important procedures and functions which require a critical analysis.

The odd part of this is the reports do not appear to be just talking about MA plans.

Doc Blows Whistle on Cigna

Cigna increased its efforts to speed up claims denial by using new software and performance measures that pressured medical directors to close cases without a full review. This according to a ProPublica  investigation. MedPage Today is citing ProPublica article. Some of this report is from ProPublica.

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

Working faster 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.

Dr. Debby Day had been working at Cigna for nearly 15 years, reviewing the cases nurses were flagging for denial or were unsure about. At Cigna and other insurers, nurses can greenlight payments. Denials have such serious repercussions for patients, many states require doctors to make the final call.

In more recent years, Day said the Cigna nurses’ work was getting sloppy. The nurses working in the Philippines sent a patient’s files to her. Increasingly, the errors in them could lead to denials if they were not corrected.

AB: Whenever I have to talk to my healthcare insurance, I find myself talking to someone in the Philippines. I have worked in the Philippines from time to time (automotive) and find them to be extremely thorough. Their English is also excellent. Unfortunately, they miss the nuances an American would pick up on during a discussion. In person, it is easy to explain or show another what you mean. On healthcare insurance issues, I would ask to be transferred back to the states. For companies, off-shoring is a function is a major cost reduction.

In her own words, Day was 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 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.

Day acknowledged some of her colleagues quickly denied requests to keep pace. Day . . .

“Deny, deny, deny. That’s how you hit your numbers. If you take a breath or think about any of these cases, you’re going to fall behind.”

The insurance company were pressuring medical directors who fell behind in reviewing cases. They went as far to threaten to fire them if they failed to work faster. Cigna was encouraging doctors to “cut and paste the denial language the reviewing nurse had prepared and quickly move on to the next case,” according to Day. This practice became so common the Cigna employees took to calling the approach “click and close.”

Cigna told ProPublica the medical directors are not permitted to “rubber stamp” nurse denials. The company expects case reviewers to “perform thorough, objective, independent, and accurate reviews in accordance with our coverage policies.”

Tracking the Output of Medical Directors

During Day’s final years at Cigna, the company was meticulously tracking the output of its medical directors on a monthly dashboard. Cigna shared this spreadsheet with more than 70 of its doctors, allowing them to compare their tally of cases with those of their peers. Day and two other former medical directors said the dashboard sent a message loud and clear: Cigna valued speed. (ProPublica and The Capitol Forum found these other former Cigna doctors independently; Day did not refer them.) One of Day’s managers in a written performance evaluation called the spreadsheet the “productivity dashboard.”

Measuring the speed and output of employees is common in many industries, from fast food to package delivery. In the use of these kinds of metrics in health care is controversial because the stakes are so high. It’s one thing if a rushed server forgets the fries with your burger. It’s another entirely if the pressure to act fast leads to wrongful denials of payment for vital care. Walgreens in 2022 dropped measurements of its pharmacists’ speed from their performance reviews after some alleged that practice could lead to dangerous mistakes.

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 to take four and a half minutes.

“Medical directors would message me and say, ‘We can’t do these cases in four minutes. Not if you want to do a good job,’” Day recalled.

Denying Claims In Bulk

As ProPublica and The Capitol Forum reported last year, Cigna also built a computer program allowing 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. At the time, Cigna said the review system was 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.

More on this later as the story develops.