We’ve been slowly working toward a theory of crapification and if we manage to sort it out, we might even develop a school of craopnomics. But in reality, Corporate America presumably already has that well codified but has yet to release the playbook to the great unwashed masses.
As much as I am of two minds about sharing personal anecdotes with readers, my recent experiences with the health insurer Cigna amount to several case studies in crapification in one nasty package. Moreover, since the American health care policy is to force even more Americans into the health insurance regime and call it “health care,” I thought my tale might elicit similar accounts from readers, as well as input from people who’ve worked in the insurance industry as to how much of what I am experiencing is incompetence versus design.
We’ll start with some examples (trust me, I have even more) of what’s been going wrong with Cigna. Then we’ll step back and consider why this might be happening.
Continuing Deterioration in Cigna Claims Processing
I am in the unusual position of having had the same policy since 1991. That enables me to speak with knowledge about how Cigna’s service has decayed over time.
The policy terms have not changed, save for price increases and some changes mandated by Obamacare, the most important being the lifting of a lifetime cap. The policy was not very good by 1991 standards, but due to the general degradation of health insurance, it is now an extremely good policy. Its most attractive features are that it has a low deductible (and no separate pharmacy deductible), is pretty cheap, and is an indemnity plan. That means I am not restricted to a network, nor am I subject to gatekeeping (I can go directly to specialists). It also covers doctors all over the world. For instance, when I was in Australia for two years, it reimbursed my doctor visits there, and has also covered medical care in the UK and Thailand.
Another big positive feature is that my Cigna policy is regulated by New York State, which means I can go to the state insurance bureau for external appeal. The few times I have, the state has come down on Cigna like a ton of bricks.
For most of my first 15 years, when I submitted claims, the would be processed quickly and without dispute. Occasionally, there would be some drama (and this would come in 6-18 month episodes) where it appeared Cigna was on some profit-increasing exercise and my policy would get included among the targets. For instance, certain charges would suddenly be haircut as being in excess of “ordinary and customary” or services that were clearly covered would be denied. One example is that New York State mandates that insurance plans cover 15 chiropractic treatments a year. Cigna started trying to deny chiropractic claims after having paid them for years. That led to a letter to the state bureau and the state told Cigna that it was out of line.
Things started taking a turn for the worse in 2007 when my policy was moved from one database to another, and the records showed it being a new policy as of that date. Claims were regularly processed incorrectly, and I’d have to tell agents to look in the legacy database to see that claims that were being denied had clearly been covered in the past (fortunately, I keep all my records and so could point to specific past claims). But in fairness, that problem looked more like an internal cock-up, since once I pointed out the mistakes, the submissions were usually reprocessed correctly.
The next ratchet down occurred in 2009 or so, when Cigna would simply not process 20% to 25% of my claims. This pattern continues to this day, although the percentage that goes “poof” now is more like 15%. And mind you, I am very healthy. Even with my low premiums, Cigna makes money on me on an annual basis, so it isn’t as if I’m seeing a ton of doctors and they’ve put me in some sort of “medical service overuser” category (not that they are allowed to do that either, BTW).
Previously, every single claim led to a letter back with the usual results, either a payment or credit against my deductible, or some explanation as to why they thought the service wasn’t covered. Suddenly, a large proportion of my claims appeared to go directly into a Cigna trash bin. And since none of my other mail (including payments of Cigna premiums) was going missing, this failure to process claims can’t be attributed to the US Postal Service going rogue. I had to start recording the date of every time I submitted a claim to Cigna, the provider name, date of service, and dollar amount and following up.
We’ll skip over some chapters to get to the most recent incidents. The latest looks like a textbook case of insurance fraud, meaning failure to honor a valid claim, and I will be sending a letter into New York State on this occurrence when I find time.
Drug claim rejection. I sent in some recent prescriptions. I pay those in cash and then send them in for reimbursement. I submitted the same paperwork that the drug store has provided for the last ten years and Cigna has heretofore accepted.
Cigna sent a letter back. The reason for not processing the claim was “Claim is missing detail charges.” They included copies of the drug store prescription information that I had sent in, which was fully legible, and included the usual information, such as the date the prescription was filled, the name and strength of the medication, the Rx number, the doctor’s name, the dollar amount.
Thus per what they sent back, there were absolutely no “detail charges” missing.
When I called Cigna, I got an astonishing run-around from the rep, who told me that Cigna had not scanned the drug store information (if they had a scanned image, I could simply demand that the claim be reprocessed) but that he could look in my records and see past prescription claims and he could see it was identical in form to the ones that had been rejected. <strong>How could he see it was the same if there were no scanned images?
Now this situation isn’t (in theory) as difficult to remedy as others, but you can see what is going on here. This looks like an effort to delay payment, and for other people who encounter the same run-around, some may not resubmit their claims before Cigna’s time limit for submission expires, so Cigna will get away with not making payments that it was required to make. (Note that Cigna has recently imposed time limits, which in theory should not apply to me, since this is a change in terms and Cigna did not comply with the state-mandated procedures for making that change, but I haven’t had time to get around to that fight).
Bloodwork runaround. I’ve get a lot of blood tests every year since 2001 for reasons not worth discussing. Until this year, Cigna reimbursed it all.
This year, it refused to pay on half the tests, claiming they were preventative in nature and hence not covered. I called Cigna and referred them to my most two previous years of bloodwork, which Cigna paid in full. Every time, the rep agreed that 1. My policy has not changed since 1991; 2. It does not differentiate between preventative and therapeutic care (the “preventative care” concept is absent from the policy) and 3. They saw no reason for the claim not to be paid.
6 reps (including a supervisor) submitted the claim to be reprocessed. That means I as the customer should get some paperwork back as of a date certain (the customer service staff would typically tell me when the letter ought to go out).
I never received anything from Cigna, which again strongly implies that the customer service reps are just for show and claims processing is simply trashing claims they don’t like.
In addition, Cigna has the usual automated prompt system you must navigate in order to speak to a live person. One of the things they ask is whether this is the first time you’ve called about this matter, and if this is not your first time, how many times you have called previously. I also learned in this process that if you respond with a number 3 or higher, your call will be disconnected when it is supposedly transferred to a customer service rep more than 50% of the time.
Doctor visit Catch-22. I saw my regular MD earlier this year. I paid via credit card even though she is a Cigna network doctor and prior to this year, I’ve had her office handle the “deal with Cigna” hassle and submit the claim. I decided to pay because my reading of Obamacare (and I’d welcome expert input) is that if the provider accepts the patient’s insurance, the medical records transfer to the insurer is seamless. If the consumer pays, my understanding is the insurer has the right, as before to ask the doctor for records if it needs them to process a claim, but is not automatically given access to them (as in their rights to my records are the same as before, as opposed to increased under Obamacare).
This usually results in some hassle with in-network doctors, since I pay the rack rate, and then Cigna tells them what the discounted rate is and reimburses me only based on the discounted rate. Then I have to go back to the doctor to get a refund. That normally goes pretty smoothly.
In this case, the doctor’s office was not willing to issue the refund. I went back to Cigna, since in those rare cases when that has happened, either Cigna needs to reimburse me based on the non-network rate or tell the doctor to issue the refund. I spoke to two reps who looked at my policy, agreed this was screwed up. Each put in the claim to be reprocessed. I even got reference numbers and dates certain when I should expect a response from Cigna.
Again, nothing came back. I called a third time. This representative maintained, contrary to what the two previous ones said, that my doctor was not a Cigna doctor. I said that wasn’t right, but if so, that meant my claim should be reprocessed at the rate I had paid for services. He tried to maintain that the “Multiplan” discount, which is a network discount calculated by a third-party vendor, was the “ordinary and customary” rate, which is utterly ridiculous (the fee for the visit was normal for NYC standards and the discount was shockingly large, 63%).
I then called my doctor’s office and told them Cigna told me that my doctor was not in the Cigna network. Outrage ensued. They then passed me back to a person in their billing department who told me that even though the doctor had been with Cigna since 2001, Cigna had said the same thing with respect to some other patients. She had submitted paperwork twice with Cigna to get it fixed, once in May and again in June and it clearly was not resolved.
What These Experiences Say About Cigna
I’d very much like to get input from readers on what has been happening here, since I’m not in the same position as most customers, given my unusual policy terms. But the flip side is that it’s well documented that when insurance customers have hospital bills, they often find numerous inexplicable and invalid charges, as well as too often have a huge uphill battle in getting a significant portion of valid charges paid. I may be running into the same treatment at a much lower level simply because I have a non-standard plan that they regard as inconvenient to process. In other words, this may be another version of what Lambert calls “code as law”. Either I accept having terms that are not in my policy imposed on me, like not having preventative care covered, or they’ll do their damndest to harass me into submitting.
And an addendum: earlier this week, after I discovered the Catch-22 problem, I received a call from an independent marketing service asking me to rate the quality of my last customer service call and tell them whether I’d recommend Cigna to a friend. The call not only allowed me to give the expected low ratings but allowed me to leave some 30 second comments. Presumably as a result of the low ratings, the service asked me to leave a number so a Cigna representative could contact me. Needless to say, no one has called, confirming my experience that Cigna’s customer service is all hat, no cattle.