ProPublica Report on Bulk Medical Claim Denials Misses the Mark

ProPublica Report on Bulk Medical Claim Denials Misses the Mark

A little more information would have gone a long way toward proving malfeasance.

A ProPublica report titled “How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them” focuses on how Cigna medical directors deny thousands of claims without reading the medical records. The outrage on social media over this practice was loud and sustained.

Unfortunately, while I have little doubt that Cigna (along with every other insurer) denies claims that absolutely should be paid, the case they describe here misses the mark. Specifically, ProPublica centers on the case of a patient who had persistent neck pain. The patient’s physician had “a hunch” that the patient had vitamin D deficiency, which “if left untreated can lead to osteoporosis.” Blood tests were ordered, and payment for the vitamin D test was denied. In issuing the denial, Cigna sent a letter to the patient that was signed by one of their medical directors.

Further investigation by ProPublica determined that the Cigna medical directors do not actually review the medical records, but simply sign off on these automated denials in bulk, with one former Cigna doctor noting, “it takes all of 10 seconds to do 50 at a time.” More outrage ensued.

As with many of these exposés, the crucial clinical details were not provided. But what was provided was that the physician ordered several blood tests through LabCorp, with LabCorp submitting a bill to Cigna for $1,126. Cigna only denied payment for the vitamin D test, priced at $358. That is all we know. There is no information on the other tests that were ordered and paid. There is absolutely no information about what ICD-10-CM diagnoses the physician submitted to the lab. There are no physician notes, no examination findings, no results from already completed testing.

Is the outrage justified? Let’s look closer. Cigna, like many other insurers, including Medicare, has clear policies on coverage for a myriad of services. Such diagnosis-to-test/procedure code coverage rules exist for much of what is done in medicine today. Each insurer, including Medicare, assesses the medical literature and determines their coverage rules and publishes them. Cigna’s policy is available on the Internet. Included in that policy and other payer policies are the ICD-10-CM codes that are approved for each particular lab test. Since it is not known what ICD-10-CM code was linked to this lab test, it is impossible to determine if the test should be covered, per Cigna’s policy. It is also unknown if LabCorp asked the physician for additional codes that might allow coverage.

Second, every reader assumed that since the doctor’s signature was affixed to the claim, the physician personally reviewed the complete medical records. The letter was not provided, so it is not clear if it was appropriate to make that assumption. Did that medical director participate in the development of the coverage policy? If so, the denial could certainly be attributed to that doctor. When I received my paycheck (back in the days prior to direct deposit), I did not assume that the CEO personally reviewed every paycheck to ensure that my pay was calculated correctly. I know that the payroll system is programmed to calculate my pay. The same applies here. The Cigna system cross-references the lab tests and the diagnoses and automatically denies tests that do not match.

Some commenters argued that the physician was in the room with the patient, determining what care was appropriate, and the payer should trust the physician. One orthopedist noted, “and that should be all that is required, a licensed physician thinks it is necessary.” In response, the orthopedist was asked, “just to play devil’s advocate, (what about an) orthopedist who says platelet-rich plasma or stem cell therapy is necessary for OA – should (that) result in coverage by all payers?” The physician then realized that the situation is much more nuanced.

It must also be noted that the lab test was performed, and the results were sent to the physician. The patient was indeed vitamin D-deficient and started supplementation. This is not the same as the physician contacting an insurer to get prior approval for imaging or surgery and receiving a denial. In such cases, there is an opportunity to speak directly with a medical director and provide additional clinical information. This denial had no direct effect on the patient’s care. The money aspect of this is important, but that is a different discussion.

Interestingly, the article notes that the denial was referred to an independent medical review company. The article notes that the test “confirms the diagnosis of vitamin D deficiency,” and therefore, the testing was appropriate. Excuse my callousness, but what the heck! That company’s reviewer justified the performance of the test by noting the result was abnormal? That is not how it works! Insurance companies play this game all the time, denying inpatient admission because the patient improved and was discharged in two days. Coverage of tests, procedures, and admissions should be based on the information at the time of the decision, not the outcome.   

The argument with vitamin D testing itself is also controversial. In this case, while the physician had a hunch the patient was deficient, and that may have led to osteoporosis causing the neck pain, shouldn’t the diagnosis of osteoporosis be established first and then vitamin D testing performed? Should all patients be screened for vitamin D deficiency? While vitamin D deficiency has been associated with several diseases, no study has yet to show that vitamin D supplementation lowers the risk of any disease. Is there simply correlation, rather than causation? Did the disease lead to low vitamin D levels, or was it an innocent bystander?

I greatly respect the reporting by ProPublica and am a sustaining member, but in this case, the inclusion of just a little more information, the diagnoses and a copy of the denial letter, would have added some crucial context that may have blunted some of the criticism of Cigna in this particular case. Then we can save our outrage for the myriad of other unacceptable practices by the commercial and Medicare Advantage payers.

Programming note: Listen to Dr. Ronald Hirsch live as he makes his Monday rounds during Monitor Mondays with Chuck Buck.


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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