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The Swift Denial of Medical Claims in the Health Insurance Industry.


The health insurance industry in the United States has come under intense scrutiny in recent times, and a prominent case has shed light on controversial practices that directly impact policyholders. In this blog, we will explore the research by ProPublica and The Capitol Forum, which reveals how the insurer Cigna employs a system called PXDX to quickly deny medical claims, resulting in harmful consequences for patients.


Unveiling Cigna’s PXDX System:

The case of Dr. Nick van Terheyden, a resident physician in Maryland, illustrates how Cigna uses the PXDX system to instantly deny medical claims. An internal analysis reveals that Cigna’s physicians deny approximately 300,000 payment requests in two months, using an algorithm that highlights discrepancies between diagnoses and acceptable procedures according to the insurer.


Consequences for Patients:

The swift denial of claims not only leaves patients with unexpected bills but also raises questions about the quality of medical care received. How does this practice affect the health of policyholders? What impact does it have on patient trust?


Legality and Ethics:

Cigna’s review system, which avoids detailed medical review, raises questions about the legality and ethics of such practices. Does this method comply with health insurance laws and regulations? Is it ethical to deny medical claims without proper review?


Economics and Insurers’ Motivations:

Why do insurers adopt systems like PXDX? It is argued that speedy denials save costs, but what is the human cost of such efficiency? How does this affect the public perception of insurers and the healthcare system overall?



Potential Changes and Reactions:

The public exposure of these practices could drive changes in the industry. This segment explores historical cases where public pressure led to reforms and proposes potential reforms that could address concerns related to the swift denial of claims.


At Functional Wellness Network, we strive to provide healthcare professionals and patients with valuable information addressing the complexities of current healthcare. We recognize the importance of staying informed about the latest trends and challenges, and we invite you to explore how improvements in healthcare, especially in the case of Cigna and its PXDX system, can influence your practice and the health of your patients.


The recent revelation about Cigna’s automatic denial practices underscores the need for fair and patient-centered healthcare. As healthcare professionals, it is crucial to be informed about how these practices affect policyholders and how we can advocate for system improvements.


Considering the significance of this issue, we would like to offer a space in our bi-weekly Zoom meetings to discuss and share relevant information. These meetings will not only be a valuable source of knowledge but also an opportunity to strengthen the connection between healthcare professionals and patients.


For those wishing to delve deeper into the impact of these practices on healthcare and the relationship with Cigna, we recommend staying informed through reliable sources (PROPUBLICA) and actively participating in discussions on how we can move towards a more equitable and patient-centered healthcare system.


At Functional Wellness Network, we are committed to your health and well-being, and we are here to support you on your journey towards improved healthcare.



Dr. Kent Nelson

Functional Wellness Network


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