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Cigna Sued Over Algorithm Allegedly Used to Deny Coverage to Hundreds of Thousands of Patients

On Behalf of | Aug 3, 2023 | Medical Malpractice |

As reported in Forbes, a lawsuit was recently filed in California against health insurer Cigna for using a software system which allowed healthcare claims to be systematically rejected in a matter of seconds without doctors ever opening patient medical records. The suit, seeking class action status, was brought by a pair of plaintiffs who were denied coverage by Cigna: (1) Suzanne Kisting-Leung was referred for an ultrasound because of a suspected ovarian cancer risk; and (2) Ayesha Smiley was tested pursuant to her doctor’s order for a vitamin D deficiency.

The complaint alleges that Cigna’s digital claims system, called PXDX, is an “improper scheme designed to systematically, wrongfully, and automatically deny its insureds medical payments owed to them under Cigna’s insurance policies.”

The suit follows a Propublica investigation in March that detailed Cigna’s software system for approving and denying claims in batches. The algorithm works by flagging discrepancies between a diagnosis and what Cigna considers “acceptable tests and procedures for those ailments,” according to the lawsuit. Over two months last year, the company denied more than 300,000 claims, spending an average of 1.2 seconds on each claim, Propublica reported. While medical doctors signed off on the denials, the system didn’t require them to open patient medical records for the review.

After the lawsuit was filed Monday, Cigna defended the software system. “PXDX is a simple tool to accelerate physician payments that has been grossly mischaracterized in the press,” spokesperson Justine Sessions said in a statement. “The facts speak for themselves, and we will continue to set the record straight.”

This situation raises questions about how technology could harm patients as more healthcare organizations look to embrace artificial intelligence (“AI”) and other new tools.

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