The Spark

the Voice of
The Communist League of Revolutionary Workers–Internationalist

“The emancipation of the working class will only be achieved by the working class itself.”
— Karl Marx

CIGNA Rejects Health Care Claims in Seconds

Sep 4, 2023

Suzanne Kisting-Leung’s doctor recommended an ultrasound because of ovarian cancer risk, but within seconds her claim for insurance coverage was rejected by CIGNA without even opening her medical records or considering her doctor’s diagnosis.

Suzanne is one of hundreds of thousands of CIGNA health insurance policy holders who fell victim to the company’s new digital claims system called PXDX. This new process systematically rejects claims in a matter of seconds without even considering the opinions of medical experts familiar with the details of patient cases.

PXDX uses an advanced software algorithm to speed up its process to deny coverage. Instead of investigating each claim individually, the algorithm reviews them in batches and broad categories. It flags discrepancies between a diagnosis and CIGNA’s corporate “standards” for “acceptable tests and procedures” for various illnesses. Those claims flagged by the algorithm are automatically denied.

During two months in 2022, CIGNA denied more than 300,000 claims, spending an average of 1.2 seconds on each claim—all without a single review of patient medical records.

Of course, this process automation is all about jacking up CIGNA’s bottom line. The more often and more quickly claims are rejected, the faster the patient premium payments are logged in company ledgers as revenue.

Other insurance companies are doing the same. Google has released new advanced tools for health care claims that use AI to organize data and “expedite” decision making. Their AI tool is already in use at Blue Shield of California and Bupa, the British health insurance giant.

Under capitalism, the greatest achievements of science and technology will always first serve the tiny minority of multi-billionaires in their mad chase after profits. And the working class will always pay the price—at least until their self-organization and militancy can successfully turn the tables.