Did Your Health Insurer Deny Medically Necessary Care? Health Insurance Denial Lawyer Scott Glovsky Can Help
It can be very unsettling when your health insurance company denies healthcare your doctor says is medically necessary. After all, you’ve been paying your premiums religiously month after month. And this treatment, medication or surgery might be lifesaving. The thought of dealing with a huge corporation like an insurance company can feel overwhelming. Working with Scott Glovsky can make your situation much better. Scott’s been representing insurance policyholders for over 20 years. In fact, he’s happiest when he fights for justice against large corporations who feel they are invincible. When these companies drag you to a low point in your life – when you may feel ignored, injured, depressed, and worried about the future – Scott can enter and make a positive difference. He may be your last chance to get justice, and he takes this job seriously. Scott may not look like a street fighter, but he can beat your insurance company. Just ask United Healthcare, Anthem Blue Cross, Blue Shield of California, Aetna, Health Net, and Kaiser Permanente.
Cigna Corporation was founded in 1982 as a merger of two different insurance companies. In fact, Cigna’s name is a mixture of letters from these companies: Connecticut General Life Insurance Company (CG) and INA Corporation (INA). Cigna is a publicly traded for profit global company, and it rebranded its health services holdings umbrella to “Evernorth” in September 2020. In February 2023, Cigna rebranded again. The holding company is now The Cigna Group. Cigna Healthcare includes all global health plans. Evernorth Health Services includes its Express Scripts pharmacy benefit manager, Express Scripts Pharmacy, Accredo specialty pharmacy, eviCore data analytics, myMatrixx PBM for worker’s compensation programs, and MDLive telehealth. In October 2023, Cigna acquired the clinical and technological capabilities of asynchronous telehealth provider Bright.md which will be folded into MDLive offerings.
With Affordable Care Act Individual and Family medical plans in 13 states in 2022, Cigna plans to add 3 more states in 2023. The company operates in California as Cigna Healthcare of California, Inc. and sells health insurance to individuals. Although its U.S. market share is only 2%, it’s the fourth largest health insurer in the country in terms of membership.
Anthem tried to purchase Cigna in 2015 for $47 billion. However, the Department of Justice blocked the merger in 2017 because it would have had anticompetitive consequences. In fact, the merger would have created the country’s biggest health insurance company.
Cigna has had its share of difficulties over the past years. It was named as one of the most hated companies in the country by the American Consumer Satisfaction Index in both 2015 and 2018. The DOJ filed a lawsuit against the company in 2020 alleging Cigna defrauded Medicare Advantage, Medicaid, and Medicare for $1.4 billion. The suit alleges that Cigna submitted diagnostic codes for conditions patients didn’t have and weren’t based on clinically reliable information. The DOJ also filed a suit in October 2022 alleging Cigna overcharged Medicare Advantage by tens of millions of dollars between 2012 and 2019 by submitting false diagnoses claiming patients were sicker than they actually were. In September 2023, Cigna agreed to pay $172 million and to enter into a corporate integrity agreement with the US Office of Inspector General to settle the October 2022 lawsuit.
In March 2023, ProPublica published a story stating that in its automated PXDX (procedure-to-diagnosis) review process, many Cigna medical directors don’t review patient records prior to making decisions on claims. As such, many claims are denied without a full and fair investigation as required by states such as California. In our Washington v. Aetna case, we found a similar situation in which the medical director we deposed stated he did not review medical records prior to denying claims.
Like other health insurance companies, Cigna has diversified its health holdings. It owns the very large Pharmacy Benefit Manager Express Scripts as well as Accredo, a specialty pharmacy. Cigna also owns eviCore healthcare, a medical benefits manager, and MDLive, a telehealth primary care network. In November 2022, Cigna invested in VillageMD-Summit, a network of primary care physicians. And in June 2023, Cigna’s Evernorth Health Solutions invested in CarepathRx Health System Solutions, a company that delivers infusion services and virtual care to health systems, physicians and hospitals.
Could a Cigna Denial Cause Even More Health Issues?
You have health insurance to care for you and your family when you are injured or sick. But too often, a member submits a claim to Cigna only to have their claim rejected. Unfortunately, health claim denials can be harmful, causing some people to go without medical care, and leaving some families to struggle with huge medical bills. In fact, this July 2022 study found that 4 in 10 American adults delayed or went without medical care in the past year because of its cost. The study also found that about 25% of adults claim they or family members have not filled a prescription or cut pills in two or even skipped medication doses due to costs. And 41% of Americans claim they have debt from medical or dental bills.
Of course, not getting needed care can cause health issues to worsen. JAMA Internal Medicine published a study showing that chronic conditions are linked to financial hardships. In other words, the greater the number of chronic conditions, the higher the likelihood of financial debt. And medical debt leads to skipping needed healthcare which in turn causes more health problems.
In another survey of individuals with chronic conditions, patients felt their insurance was essentially useless when their insurers denied or delayed medically necessary care. Over 40 percent of patients who were denied care waited over a month for a ruling on their appeal. Nearly a third said they waited over 3 months.
Unfortunately, when insurance companies deny or delay care, they are telling doctors that they know what’s best for their patients. There are many ways that insurers delay medically necessary care:
- Insurers require “step therapy” which mandates patients to take alternative and usually cheaper medications or treatments instead of what the doctor prescribed. Patients can only get the doctor recommended care after other options fail to help the health issue.
- Oftentimes insurance companies ask for prior authorization before they will approve a procedure or prescription medication.
- Prescription formularies have multiple tiers (typically based on cost) and insurance companies won’t pay for the highest tier medications.
- Insurance companies tell pharmacists that they will only cover less expensive medications in the same class, even though the other medications in the class have different chemical structures.
What Are Common Denials From Insurers like Cigna?
While there are many different reasons that insurers deny claims, the main reason is typically their profits. The less insurance companies approve, the higher their profits. Common reasons that insurers such as Cigna give for denying claims include:
- Treatment or medication is not medically necessary
- Patient records are incomplete and don’t show the treatment or a diagnosis
- Medication or procedure is experimental or investigational
- Treatment or its diagnosis has an incorrect code
- Prescribed treatment is an elective or non-essential procedure and not covered by the insurer
- Incorrect or incomplete application
- Patient didn’t get pre-certification or prior authorization
- Claim arrives too late
- Patient portion such as the deductible or co-pay isn’t paid
- Insurance information is not accurate or complete
- Requested provider or facility is out-of-network
Cigna, like other health insurers, must give you its denial as well as the reason for its denial in writing. The denial must include instructions on how to appeal the company’s decision. You can learn more about how to fight your health insurance denial in our downloadable eBook.
California regulates insurance companies. There is the Department of Insurance and the Department of Managed Healthcare. California stipulates that all health insurance companies have an internal appeals process. If insurers deny appeals, then policyholders have additional ways to appeal their claims.
It may appear daunting if your claim is denied and you must now learn how the appeals process works. We don’t suggest trying to handle this on your own. A Cigna health insurance denial lawyer like Scott Glovsky has been assisting policyholders like you for over 20 years. Scott can help determine how to optimize your chance of overturning the denial. He will ask you questions like is your health insurance plan an ERISA plan or a non-ERISA plan. He will ask you if your plan is self-funded. The reasons for these questions are that the path you take will depend on your individual circumstances. Scott Glovsky can assist you in the appeals process, whether you had a denial or a claim underpay. It will aid both your health and your future to have a skilled health insurance denial attorney on your side – a person who watches your back and is concerned about your future.
Appealing a Cigna Health Insurance Denial
As a Cigna policyholder, you have the right to appeal a denial or underpay. According to Cigna’s website, you must appeal the decision within 180 calendar days of the date of the denial letter or the date of the last payment modification. The website also says the review will be completed within 60 days. In addition, your provider will get notice of the resolution within 75 business days of receipt of the original dispute. Note that Cigna allows you to file more than one internal appeal. The first appeal is called a “first-level appeal” and the second appeal is called a “second-level appeal.” The two appeals are reviewed by different Cigna employees. Medical necessity appeals are reviewed by three employees.
Do States Set Standards for a Health Insurance Company’s Appeal Process?
Insurance companies must comply with state laws. As an example, for California Affordable Care Act plans, the insurance company must agree or disagree with your appeal within 30 days for a preauthorization (meaning you haven’t yet received the treatment) and within 60 days for a service that you have already received. In some cases, if your appeal is urgent, the insurer must make its determination within 72 hours. For non-ACA plans, you must adhere to your specific plan’s appeals process and timing.
California law also dictates that if you are denied your internal appeal, you have the right to an external appeal. This external appeal is known as an IMR, or Independent Medical Review. When you get an IMR, independent doctors outside of your insurance plan review your situation. The process is to ask the Department of Managed Healthcare for an IMR. The DMHC reviews your case and determines your eligibility.
But keep in mind it is best to speak with a qualified health insurance attorney before you request an IMR. The reason is that this lawyer can help determine the best path to optimize your chances of receiving the care you need. And it may be the case that it is much more difficult to get this care if the IMR upholds your insurance company’s decision.
For Cigna plans, review your specific policy to see if there is an arbitration clause. We recommend speaking with a health insurance lawyer about the arbitration clause since it may help determine your best course of action.
Should I Appeal a Cigna Health Insurance Denial?
You need to adhere to Cigna’s policies. And typically, your healthcare provider submits claims he or she feels are necessary. So, if you want to get the treatment or medication that your doctor prescribed, then you should appeal Cigna’s denial. But consider some information from the Centers for Medicare and Medicaid Services. Across all non-group qualified health plans (QHPs) in 2021, 16.6% of in-network claims were denied. And policyholders only appealed less than 0.2% of denied in-network claims. Unfortunately, insurance companies upheld 59% of their denials. While overall only 1.7% of denied claims were based on medical necessity, the numbers were much higher for some insurance company plans in certain states. For example, Cigna Silver EPO plans in Tennessee denied 37% of claims for medical necessity. And Cigna Silver EPO plans in Virginia denied 28% of claims for medical necessity.
The good news is that in some states like California and Nevada, the denial rate was closer to 0%-2%. And it is important to keep in mind that 41% of claim denials across all ACA plans were overturned during the appeals process. 41% is a high enough number to move forward with appealing a decision when you need the medical care. We recommend that you speak with an experienced health insurance attorney before submitting an appeal because this lawyer can help guide your efforts. You can read tips about how to optimize your chances of a successful appeal here.
Cigna Duties When Reviewing Claims
Cigna, like all other health insurance companies, has duties it must adhere to when reviewing your claim. If Cigna doesn’t abide by these duties, then you have additional options including legal action. Cigna must approve or deny your claim promptly. Promptly is defined by state law. It must thoroughly investigate your claim and not simply look for reasons to deny your request. Cigna needs to consider all reasons why your claim might be medically necessary. And not just anyone can review your claim. A qualified medical professional must review your request.
Questions and Answers About Cigna Coverage Denials
If you have been denied a healthcare claim, you may have many questions, including:
What if Cigna Won’t Pay for a Service I Already Received?
You can appeal Cigna’s decision through its appeal process. You may ask your doctor to get involved with supporting information. If Cigna maintains its denial, you can ask for an external independent medical review with the Department of Managed Healthcare. If the DMHC IMR determines Cigna must cover your service, then Cigna will have to pay your claim.
What if Cigna’s Denial Was Because I Didn’t Have Prior Authorization?
There are some healthcare services for which insurance companies require prior authorization. These services are often expensive. There may be a good reason why you didn’t have prior authorization – perhaps it was a medical emergency. At this point, you might want to get a skilled health insurance lawyer involved to help you get reimbursed for the care you already received.
When Should I Get an External Review of My Cigna Denial and When Should I Think About Speaking With an Attorney?
The actions you take depend on the type of health insurance plan you have. For example, you might have an ERISA plan if you get health insurance from a private employer. You need to follow the appeals process for ERISA plans before you take legal action. That said, you may want to contact an experienced health insurance attorney before you file the appeal because this lawyer can help direct your appeal. Learn more about appealing a medical necessity denial with an ERISA plan here. If you have a non-ERISA plan, you have more options. Non-ERISA plans include plans from a government employer, from a religious organization, and more. Learn more about external reviews for non-ERISA plans here. Keep in mind that when an external review upholds your health insurer’s denial, it may be more difficult to get the care you seek.
States also dictate the appeal and review process. For example, in California, a policyholder cannot be forced to submit more than two appeals before filing a lawsuit against the insurance company.
What Kinds of Claim Denials Can Get an Independent Medical Review?
When you want an external review, you must go through the Department of Managed Healthcare. Typically, you have the right to an IMR if you appealed your insurer’s decision and it didn’t respond in the allotted timeframe. You also have this right if your health insurer deemed your treatment request as not medically necessary or experimental/investigational.
How Attorney Scott Glovsky Can Help if You’ve Had a Cigna Coverage Denial
Scott Glovsky has been fighting health insurance companies for over 20 years. He’s helped individuals like you who were denied coverage for medically necessary care including medication denials, surgery denials, emergency room denials, and more. Like other people with health insurance, you’ve paid your premiums month after month, expecting your insurer to care for you when you need it. But unfortunately, insurers like Cigna may carry out many practices that deny, delay or underpay coverage, thus increasing their bottom-line profits.
Scott Glovsky is the Cigna health insurance denial attorney you want by your side when it’s time to fight your insurance company. The Law Offices of Scott Glovsky understands how health insurance companies operate. We have a successful track record of getting policyholders the care they’ve been denied. We’ve helped change many clients’ lives and yours can be changed too. Our team can help file your appeal with Cigna, help create a case for an external appeal, or file a lawsuit to help ensure you get the care you’ve been paying for. Scott has spent his career going toe-to-toe with several corporate attorneys. He’s been highly successful by being better prepared to stand on the fair and just side of every argument. When you’re looking for a great outcome to your health insurance denial, contact Scott Glovsky.