In recent days, health plan members and the U.S. Dept. of Labor (DOL) filed lawsuits against The Cigna Group and UnitedHealth Group, respectively, over what they call unfair, systematic patterns of claims denials. Experts tell AIS Health, a division of MMIT, that the processes behind claims denials in the commercial space — and the purpose-built software that carriers use to adjudicate those claims — are likely to be the subject of intense legal and political scrutiny in coming years.
Plan members seeking to form a legal class filed a suit against Cigna in a California federal district court on July 24. The complaint centers on what it calls an “illegal scheme to systematically, wrongfully, and automatically deny” claims using “an algorithm known as PxDx” that Cigna “relies on…to automatically deny payments in batches.”