Is your health insurance provider a rejection mill?
By Patrick Rucker, The Capitol Forum, and David Armstrong, ProPublica
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In late 2020, Dr. Debby Day said her bosses at Cigna gave her a stark warning. Work faster, or the company might fire her.
That was a problem for Day because she felt her work was too important to be rushed. She was a medical director for the health insurer, a physician with sweeping power to approve or reject requests to pay for critical care like life-saving drugs or complex surgeries.
She had been working at Cigna for nearly 15 years, reviewing cases that nurses had flagged for denial or were unsure about. At Cigna and other insurers, nurses can greenlight payments, but denials have such serious repercussions for patients that many states require that doctors make the final call.
In more recent years, though, Day said that the Cigna nurses’ work was getting sloppy. Patient files that nurses working in the Philippines sent to her, she said, increasingly had errors that could lead to wrongful denials if they were not corrected.
Day was, in her own words, persnickety. If a nurse recommended denying coverage for a cancer patient or a sick baby, she wanted to be certain it was the right thing to do. So Day said she researched guidelines, read medical studies and scrutinized patient medical records to come to the best decision. This took time. She was clearing fewer cases than many of her peers.
Some of her colleagues quickly denied requests to keep pace, she said. All a Cigna doctor had to do was cut and paste the denial language that the nurse had prepared and quickly move on to the next case, Day said. This was so common, she and another former medical director said, that people inside Cigna had a term for these kinds of speedy decisions: “click and close.”
“Deny, deny, deny. That’s how you hit your numbers,” said Day, who worked for Cigna until the late spring of 2022. “If you take a breath or think about any of these cases, you’re going to fall behind.”
In a written response to questions, Cigna said its medical directors are not allowed to “rubber stamp” a nurse’s recommendation for denial. In all cases, the company wrote, it expects its doctors to “perform thorough, objective, independent and accurate reviews in accordance with our coverage policies.” The company said it was unaware of the use of the term “click and close” and that “such behavior would not be tolerated.”
During Day’s final years at Cigna, the company meticulously tracked the output of its medical directors on a monthly dashboard. Cigna shared this spreadsheet with more than 70 of its doctors, allowing them to compare their tally of cases with those of their peers.
Day and two other former medical directors said the dashboard sent a message loud and clear: Cigna valued speed. (ProPublica and The Capitol Forum found these other former Cigna doctors independently; Day did not refer them.) One of Day’s managers in a written performance evaluation called the spreadsheet the “productivity dashboard.”
Measuring the speed and output of employees is common in many industries, from fast food to package delivery, but the use of these kinds of metrics in health care is controversial because the stakes are so high. It’s one thing if a rushed server forgets the fries with your burger.
It’s another entirely if the pressure to act fast leads to wrongful denials of payment for vital care. Walgreens in 2022 dropped measurements of its pharmacists’ speed from their performance reviews after some alleged that practice could lead to dangerous mistakes.
ProPublica and The Capitol Forum examined Cigna’s productivity dashboards for medical directors from January and February 2022. These spreadsheets tallied the number of cases each medical director handled. Cigna gave each task a “handle time,” which the company said was the average amount of time it took its medical directors to issue a decision.
Day and others said the number was something different: the maximum amount of time they should spend on a case. Insurers often require approval in advance for expensive procedures or medicines, a process known as prior authorization.
The early 2022 dashboards listed a handle time of four minutes for a prior authorization. The bulk of drug requests were to be decided in two to five minutes. Hospital discharge decisions were supposed to take four and a half minutes.
“Medical directors would message me and say, ‘We can’t do these cases in four minutes. Not if you want to do a good job,’” Day recalled.
As ProPublica and The Capitol Forum reported last year, Cigna built a computer program that allowed its medical directors to deny certain claims in bulk. The insurer’s doctors spent an average of just 1.2 seconds on each of those cases.
Cigna at the time said the review system was created to speed up approval of claims for certain routine screenings; the company later posted a rebuttal to the story.
A congressional committee and the Department of Labor launched inquiries into this Cigna program. A spokesperson for Rep. Cathy McMorris Rodgers, the chair of the congressional committee, said Rodgers continues to monitor the situation after Cigna shared some details about its process. The Labor Department is still examining such practices.
One figure on Cigna’s January and February 2022 dashboards was like a productivity score; the news organizations found that this number reflects the pace at which a medical director clears cases.
Cigna said it was incorrect to call that figure on its dashboard a productivity score and said its “view on productivity is defined by a range of factors beyond elements included in a single spreadsheet.”
In addition, the company told the news organizations, “The copy of the dashboard that you have is inaccurate and secondary calculations made using its contents may also be inaccurate.” The news organizations asked what was inaccurate, but the company wouldn’t elaborate.
Nevertheless, Cigna said that because the dashboard created “inadvertent confusion” the company was “reassessing its use.”
Day was afraid to look at the dashboards. Anyone could see that by Cigna’s measures, she was a laggard. In January 2022, only a third of her peers had lower scores, and in February 2022, it was just a quarter.
In a recorded phone call and in emails with supervisors, Day complained that Cigna’s metrics failed to account for the quality of decisions. She said she and others asked higher-ups how often medical director decisions were overturned on appeal but nobody would say.
Day gave Cigna written permission to discuss her employment with ProPublica and The Capitol Forum.
The company described Day as a “disgruntled former employee” and said her “personal view is not an accurate representation of the work of the many medical directors and clinicians we employ.”
Cigna added that prior authorization requests are often time-sensitive and the company’s “mission is to ensure our patients receive the right care as quickly as possible.”
Cigna rejected the assertions that denying cases was an effective way of working faster. “Even if medical directors were incentivized to review more claims — which they are not — it makes no sense to suggest that this incentivizes denials; it would be far quicker to approve all claims,” the company spokesperson wrote.
The insurer said that denials take more time because they require a deeper review of clinical data, potentially requesting additional reviews by senior clinical directors, drafting denial letters and possibly phoning the treating physicians.
But another doctor who had worked at Cigna also said that denying a request for payment was far quicker than approving one since the nurses served up language that could be used to justify the denial.
That former Cigna medical director said, “Sometimes you just have to accept the nurse and click and close if you had too much work.” (That doctor asked not to be named because they feared repercussions if they commented publicly.)
When Debby Day got her job at Cigna in November 2005, she thought it was a godsend.
She had been working for a health insurance startup in North Carolina. The charismatic founder of the company, Day said, had told her and a handful of principal executives to expect a windfall when the company went public. That never happened, and Day was eventually left with no job and no severance.
When a recruiter mentioned the medical director job at Cigna, it sounded like a perfect fit. The job was based in North Carolina, but Cigna didn’t mind that she was licensed in California, where she did her residency at Harbor-UCLA Medical Center. She was ready to leave the executive track, and the position allowed her to put her medical training to good use without the daily grind of working in a clinic.
The daughter of an ophthalmologist, Day had watched her father perform eye surgery when she was a child, and she found medicine fascinating. When Day started practicing, she learned quickly that while she enjoyed the intellectual challenges of medicine, the hands-on work of seeing patients drained her. As a medical director, she said, “I could really take care of patients without having to talk to them all day long.”
Cigna, like all health insurers, makes patients get approval in advance for certain treatments. Day became one of the people who reviewed these prior authorization requests, deciding what to cover and what to deny.
Everyone Day worked with was under one roof in Raleigh, North Carolina. The office buzzed with conversations among colleagues, and she was able to consult with specialists on complex cases.
She never felt pressure to do anything but make the right decision for the patient. At the same time, she said, she didn’t hesitate to reject treatment she thought was improper.
A couple years into her time at Cigna, Day noticed some doctors prescribing a costly treatment called intravenous immunoglobulin, or IVIG, that helps patients with weakened immune systems fight off infections.
Only she found they were prescribing it in cases where it didn’t make any medical sense. That wasn’t good for patients or for Cigna. “Some of these guys were pouring it into every patient they could get their hands on and then making hundreds of thousands of dollars billing for it,” she recalled.
At the time, Cigna didn’t have a policy for when IVIG should be used, so Day developed one based on the scientific evidence available at the time. Day said this saved millions of dollars and that Cigna rewarded her with bonuses and stock options.
“In my head I truly believed that you could marry good health care with business,” she said.
As Day neared the end of her first decade at Cigna, the company closed regional offices in favor of a nationwide review system, she said. With medical directors working from home, Day could no longer pop down the hallway to consult with doctors in other specialities.
Cigna had used a productivity dashboard for years, but by 2019, these metrics began playing a more prominent role in the company’s evaluations of medical directors, Day said.
Now, making a fast decision seemed more important than making the right decision, she said. In February 2019 emails to her managers, Day openly questioned this system.
Her boss responded: “We all understand that many cases are involved and take more time,” he wrote. “We have tried to account for that additional time in the allotment allowed for certain cases.”
Still, he made it clear that transaction volume — the metric on the dashboard that was similar to a productivity score — was one of the factors “we use to determine merit raises, bonus” and stock awards. When asked about this, Cigna said that “any assertion that our Medical Directors’ compensation (cash or stock) is tied to denials or their handle time for cases is false.”
In that same 2019 email, Day’s boss added, “We want to assist every medical director who wishes to improve his or her efficiency.”
Day shot back, “Some of our newer MDs are quite terrified of the ‘counting,’” she wrote. “All ask — ‘how is quality measured?’”
Soon, Day realized that her boss wasn’t talking in the abstract about improving efficiency; he was talking about her. She learned that managers were going to help her pick up the pace of her reviews.
When bosses reached out, they didn’t discuss whether she was making the right call, only how long it took her to decide, she said.
By then, Day said, Cigna had shifted much of the nursing work to the Philippines. She found mistakes in the case files that these nurses sent. In an email to Day, a fellow medical director lamented the amount of time it took to untangle one case and said the reports by “the overseas nurses” were “messes.”
Some of the more astonishing problems that Day spotted have stayed with her. In a case involving a newborn who needed an epilepsy evaluation, Day noticed that a Cigna nurse had listed the mother’s name as the patient, rather than the baby’s.
Day fixed that mistake, avoiding what certainly would have been a denial. In another case, a nurse recommended denying payment for an ultrasound of the neck because the treatment wasn’t medically necessary. But the nurse had gotten the body part wrong.
It was a hip that was injured, and the imaging was needed. An appeal that landed on Day’s desk involved Cigna’s decision to reject payment for a test because it wasn’t medically necessary for a patient with a sexually transmitted disease. But Day figured out that the patient had toenail fungus, not an STD.
Day said her bosses didn’t want to hear that she was catching errors. By October 2020, Cigna had placed Day on a performance improvement plan that required her to raise her “productivity level” — referring to the score on the dashboard — to at least 70%, which would be a significant jump for her but was slightly below the median for medical directors.
The company made the consequences crystal clear: If she failed to successfully complete the plan, she could be terminated.
ProPublica and The Capitol Forum asked Cigna how it calculated that score, but the company wouldn’t say. “Transaction volume helps gauge productivity and efficiency — the amount of work done, not the speed at which it is done,” a Cigna spokesperson wrote. The company said this metric measured the time a medical director spent on tasks involving medical judgment versus other work, such as internal meetings or training.
On the early 2022 productivity dashboard, though, a different calculation could explain Day’s score, and this math reflects how fast medical directors reviewed cases. ProPublica and The Capitol Forum multiplied the number of cases Day handled by the time Cigna allotted for each type of case, then divided that total by the hours she worked that month.
The resulting percentage equaled her score. Medical directors who spent every available minute of their workdays clearing cases within the time constraints Cigna set would score at least 100%. Indeed, some medical directors had scores greater than 100%, meaning they cleared cases in even less than the allotted time.
The newsrooms’ formula accurately reproduced the scores of 87% of the Cigna doctors listed; the scores of all but one of the rest fell within 1 to 2 percentage points of the number generated by this formula. When asked about this formula, Cigna said it may be inaccurate but didn’t elaborate.
Day said her bosses told her that the way to boost her score was to review more cases during her normal work hours.
Responding to questions, Cigna said the productivity dashboard was “primarily used to ensure that we have enough medical directors to perform the amount and type of work that needs to be done.” It is not used, the company said, to evaluate the performance of medical directors or track the speed at which individual doctors do their work.
Cigna, however, later said of the dashboard that “in the unusual situation that a medical director is a significant outlier to peers performing similar types of reviews, managers might use this metric as one data point to understand and discuss the variance with the medical director.” It also said Day was placed on a performance improvement plan “to help her meet the most basic standards to support patient care.”
During the time Day spent on the performance improvement plan, she refused to change her approach, which she felt was necessary to make the right call.
In December 2020, she appealed to the human resources department, figuring that colleagues there would see that it was wrong to fire a medical director for taking care to decide critical medical questions.
She was wrong.
“You feel that the time constraints/metrics, which are in place to review these cases are unreasonable, for some cases are very complex consisting of multiple pages to review,” a Cigna human resources employee wrote, summing up Day’s feelings as the matter escalated.
And while Day’s supervisor “appreciates your attention to detail,” the human resources employee wrote, he “also realizes that there are metrics in place that he must hold everyone to.”
When asked about this, Cigna said, “Dr. Day raised questions about her performance improvement plan through appropriate internal ethics channels available to all employees, and there was no wrongdoing found.”
Eventually, the daily stress of being pushed to work faster coupled with the threat of being fired took a toll on Day. Sleepless and fighting depression, Day was at the breaking point.
“I actually sort of had a mental breakdown,” she recalled.
On a recorded call with her boss about her lagging productivity score, Day brought the subject back to the quality of the decisions she was making. Her boss made it sound like Day was a broken record.
“We have the same discussion every time we talk,” he said. While saying “nobody’s asking you not to do quality work,” her boss said, “you must know I just have to redirect our discussion.”
But Day continued: “When there is no measurement of quality, then the discussion will continue to have that element to it.”
The supervisor said he heard Day’s concerns “loud and clear” but warned that “at the end of the day, we need to get your productivity up and we don’t have a lot of time to do that.”
The focus on metrics was proof Cigna was losing its way, Day told her boss. When she started working at Cigna 15 years earlier, there was a “commitment to quality and taking care of our customers.” Day said that it was still important to her and other medical directors that “we go home at the end of the day and think we’ve done a good job for Cigna.”
In a response to questions, Cigna said the supervisor, who works in California, was unaware that he was being recorded and that under that state’s laws, it is illegal to record a private phone call without all parties’ consent. Day said that she was in North Carolina during the call and that North Carolina law allows a person on a call to record without getting the consent of others.
Day took a monthslong leave from the job in mid-2021 that allowed her to work part time, and she found a therapist who helped her manage the depression. When she returned, Day said, it was more of the same.
In the late spring of 2022 she decided to retire from Cigna.
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