The Facts about Cigna Healthcare's
Claims Review Process
A recent media story riddled with factual errors and gross mischaracterizations may lead to a misunderstanding and distorted view of a simple process used by Cigna Healthcare and other health insurers to expedite payments to physicians and other providers. We are committed to being transparent about our policies and practices, and we are proud of the work our medical directors and other clinical experts do every day to help patients get the care they need and achieve value for both patients and their health plans.
Here are 8 key facts about one of our tools to expedite payments to clinicians:
1. PxDx – or “procedure to diagnosis” – is a simple process that has successfully helped us accelerate payments to physicians for common, relatively low-cost tests and treatments over the last several years.
The post-service review process works through software that matches the codes submitted by the physician with diagnosis codes that are considered medically necessary for a procedure under Cigna's publicly posted clinical coverage policies.
Claims that are denied can simply be re-submitted with an updated diagnosis code (as noted to the physician on the letter we send to them) and automatically paid; or appealed.
2. This process is not prior authorization. Patients are not denied care in any way – this review occurs after the patient has received treatment and once their physician bills for the treatment.
Services subject to these reviews are only considered medically necessary for specific diagnoses and are not complex enough to require prior authorization or “pre-approvals”.
3. This process is only used for a small group of approximately 50 low-cost tests and procedures.
We use PxDx to review claims for low-cost procedures that are only covered for specific diagnoses – such as: dermabrasion, chemical peels, or vitamin D screenings. For example, there are more than 200 diagnosis codes where Vitamin D tests are shown to be medically necessary, and we automatically pay the claims when the codes match. But unless a patient has a specific diagnosis for which Vitamin D testing is indicated, the test is considered not medically necessary and does not improve or change treatment recommendations, according to research by the American Board of Internal Medicine.
All other procedures are typically not subject to PxDx review. That includes procedures such as most ultrasounds.
4. The vast majority of claims reviewed through this process are automatically paid.
94% of claims that are subject to this review are automatically approved and paid. Claims that are denied payment through this process represent less than 1% of our total volume of claims.
5. Most individuals do not experience any additional costs if their claim is denied via PxDx.
If a patient received care from an in-network provider, the provider should not bill them if payment on a specific service is not paid via PxDx.
6. The review involves simple sorting technology that has been used for more than a decade – it matches up codes, and does not involve algorithms, artificial intelligence, or machine learning.
7. PxDx is largely based on processes used by the Centers for Medicare & Medicaid Services (CMS) and similar processes are used by other health insurers.
For example, when a physician bills CMS for procedures but does not include a diagnosis code that is considered appropriate under Medicare coverage guidelines, CMS will administratively deny the claim, and there is no opportunity for the physician to appeal with a peer-to-peer discussion. Because we value our partnerships with physicians, our process ensures that medical directors review the claims where codes don’t match and are available to discuss our determination with the treating physician so that, if warranted, the physician may resubmit the service with the correct code.
8. Savings achieved through this claims review process benefit our clients and our customers – not Cigna’s bottom line – and there is no incentive for our medical directors to deny claims.
Our company does not profit by denying claims – period. Savings from lower medical costs go to our clients – employers, government and non-profit organizations and their employees, families and patients they serve. These savings can help the client and their plan to control premium costs or offer expanded health benefits, as examples.