Patrick Rucker of The Capitol Forum and Maya Miller and David Armstrong of ProPublica won the April Sidney Award for exposing CIGNA’s policy of rejecting health insurance claims without opening their files in a co-published investigation.
Over two months in 2022, CIGNA doctors rejected over 300,000 claims, spending an average of 1.2 seconds on each. CIGNA, which administers the health insurance plans of 18 million people, created an “auto-denial” computer system that allows its doctors to reject a claim on “medical grounds” without even opening the patient’s file.
Insurance company doctors are required by law to review case files and use their professional judgment to decide what’s medically necessary. However, according to former CIGNA employees, the company outsourced the determination to an algorithm, which flags mismatches between diagnoses and CIGNA-approved treatments. The company doctor’s only role is to click “send” on batches of claims.
“We literally click and submit,” one former CIGNA doctor told the reporters. “It takes all of 10 seconds to do 50 at a time.”
This algorithmic review happens after care has already been delivered, leaving unsuspecting patients stuck with surprise bills.
A doctor whose own claim was suspiciously denied pushed forward with a series of appeals but CIGNA, and other insurers, know that most people will give up and pay. They expect only 5% to appeal.
“This investigation impressed our judges with its originality and depth of reporting,” said Sidney judge Lindsay Beyerstein, “This story challenges the states to protect consumers from the predatory use of health insurance algorithms in place of professional judgment.”
Rucker is a financial reporter for The Capitol Forum. As a foreign correspondent, Rucker reported from Havana for the Financial Times and Mexico City for Reuters.
Miller is an engagement reporter at ProPublica working on community-sourced investigations. Her reporting focuses on health care, environmental health and housing.
Armstrong is a reporter at ProPublica, specializing in health care investigations. He joined ProPublica in March 2018.