New lawsuit accuses health insurer Cigna of denying claims in bulk

An algorithm, not a doctor, predicted a rapid recovery for Frances Walter, an 85-year-old Wisconsin woman with a shattered left shoulder and an allergy to pain medicine. In 16.6 days, it is estimated, she would be ready to leave her nursing home.

On the 17th day, her Medicare Advantage insurer, Security Health Plan, followed the algorithm and cut off payment for her care, concluding she was ready to return to the apartment where she lived alone. Meanwhile, medical notes in June 2019 showed Walter’s pain was maxing out the scales and that she could not dress, go to the bathroom, or even push a walker without help. 

It would take more than a year for a federal judge to conclude the insurer’s decision was “at best, speculative” and that Walter was owed thousands of dollars for more than three weeks of treatment. While she fought the denial, she had to spend her life savings and enroll in Medicaid just to progress to the point of putting on her shoes, her arm still in a sling.

Health insurance companies have rejected medical claims for as long as they’ve been around. But the investigation found artificial intelligence is now driving their denials to new heights in Medicare Advantage, the taxpayer-funded alternative to traditional Medicare that covers more than 31 million people.

Behind the scenes, insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment. The denials that follow are setting off heated disputes between doctors and insurers, often delaying the treatment of seriously ill patients who are neither aware of the algorithms nor able to question their calculations.

Older people who spent their lives paying into Medicare, and are now facing amputation, fast-spreading cancers, and other devastating diagnoses, are left to either pay for their care themselves or get by without it. If they disagree, they can file an appeal, and spend months trying to recover their costs, even if they don’t recover from their illnesses.

“We take patients who are going to die of their diseases within a three-month period of time, and we force them into a denial and appeals process that lasts up to 2.5 years,” Chris Comfort, chief operating officer of Calvary Hospital, a palliative and hospice facility in the Bronx, N.Y., said of Medicare Advantage. “So what happens is the appeal outlasts the beneficiary.”

In other words, "Deny until dead".  Or don't diagnose or treat patients with less than six months to live.

The algorithms sit at the beginning of the process, promising to deliver personalized care and better outcomes. But patient advocates said in many cases they do the exact opposite — spitting out recommendations that fail to adjust for a patient’s individual circumstances and conflict with basic rules on what Medicare plans must cover.

“While the firms say [the algorithm] is suggestive, it ends up being a hard-and-fast rule that the plan or the care management firms really try to follow,” said David Lipschutz, associate director of the Center for Medicare Advocacy, a nonprofit group that has reviewed such denials for more than two years in its work with Medicare patients. “There’s no deviation from it, no accounting for changes in condition, no accounting for situations in which a person could use more care.”

Medicare has its own set of guidance (rules) for benefit determination as set forth in the Code of Federal Regulations. 

As the influence of these predictive tools has spread, a recent examination by federal inspectors of denials made in 2019 found that private insurers repeatedly strayed beyond Medicare’s detailed set of rules. Instead, they were using internally developed criteria to delay or deny care. Although some insurers follow Medicare's guidelines private insurers often set their own guideline.  Since MA plans are private plans they are free to do so unless Medicare restricts it.

In interviews, doctors, medical directors, and hospital administrators described increasingly frequent Medicare Advantage payment denials for care routinely covered in traditional Medicare. UnitedHealthcare and other insurers said they offer to discuss a patient’s care with providers before a denial is made. But many providers said their attempts to get explanations are met with blank stares and refusals to share more information. The black box of AI has become a blanket excuse for denials. 

New lawsuit accuses health insurer Cigna of denying claims in bulk