Patrick Rucker of The Capitol Discussion board and Maya Miller and David Armstrong of ProPublica gained the April Sidney Award for exposing CIGNA’s coverage of rejecting health insurance claims without opening their files in a co-published investigation.
Over two months in 2022, CIGNA docs rejected over 300,000 claims, spending a median of 1.2 seconds on every. CIGNA, which administers the medical insurance plans of 18 million individuals, created an “auto-denial” laptop system that enables its docs to reject a declare on “medical grounds” with out even opening the affected person’s file.
Insurance coverage firm docs are required by legislation to overview case recordsdata and use their skilled judgment to determine what’s medically vital. Nevertheless, in accordance with former CIGNA staff, the corporate outsourced the willpower to an algorithm, which flags mismatches between diagnoses and CIGNA-approved therapies. The corporate physician’s solely function is to click on “ship” on batches of claims.
“We actually click on and submit,” one former CIGNA physician advised the reporters. “It takes all of 10 seconds to do 50 at a time.”
This algorithmic overview occurs after care has already been delivered, leaving unsuspecting sufferers caught with shock payments.
A physician whose personal declare was suspiciously denied pushed ahead with a sequence of appeals however CIGNA, and different insurers, know that most individuals will surrender and pay. They anticipate solely 5% to enchantment.
“This investigation impressed our judges with its originality and depth of reporting,” mentioned Sidney decide Lindsay Beyerstein, “This story challenges the states to guard customers from the predatory use of medical insurance algorithms instead of skilled judgment.”
Rucker is a monetary reporter for The Capitol Forum. As a overseas correspondent, Rucker reported from Havana for the Monetary Instances and Mexico Metropolis for Reuters.
Miller is an engagement reporter at ProPublica engaged on community-sourced investigations. Her reporting focuses on well being care, environmental well being and housing.
Armstrong is a reporter at ProPublica, specializing in well being care investigations. He joined ProPublica in March 2018.