Title: Cigna Faces Lawsuit in California over Alleged Unlawful Use of Automated System in Insurance Claims Review
California, [Date] – Healthcare provider Cigna is facing a lawsuit in California, with allegations that it unlawfully reviewed insurance claims using automated systems instead of human review. The lawsuit, filed by a group of plaintiffs, claims that Cigna’s claim reviews were not “thorough,” “fair,” or “objective,” as they were allegedly determined by computer algorithms without any proper investigation.
One of the key accusations in the complaint is that Cigna’s PXDX system, an automated process used to assess insurance claims, automatically denies claims based on discrepancies between diagnoses and what the company considers acceptable tests and procedures. The plaintiffs argue that such an algorithmic review process prioritizes profit over patient care and eliminates the need for review by doctors and professionals.
Cigna, however, strongly disputes these allegations. The insurer maintains that the company utilizes technology to verify codes for low-cost procedures, aiming to expedite physician reimbursement. According to Cigna, the review process does not result in the denial of care, and if codes are submitted incorrectly, clear guidance on resubmission and appeals is provided.
Cigna further clarifies that PXDX is a review system designed to match submitted codes with medically necessary diagnoses, emphasizing that it is not an algorithm or artificial intelligence system.
The crux of the lawsuit’s argument is that PXDX enables Cigna to deny claims it had previously paid, effectively eliminating the need for individualized reviews and reducing labor costs. This practice potentially violates California’s requirements for a thorough and fair claim review process.
The outcome of this lawsuit could have significant implications for Cigna and the insurance industry as a whole. It raises important questions about the role of automated systems in insurance claim reviews and the potential impact on patient care.
As the legal battle unfolds, it remains to be seen how the court will determine whether Cigna’s use of automated systems complies with California’s claim review regulations and the determination of what constitutes a “thorough” and “fair” review process.
Jala News will continue to provide updates on this case as it progresses through the legal system, ensuring readers stay informed about the implications for the healthcare industry and patient rights.
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