A Doctor at Cigna Said Her Bosses Pressured Her to Review Patients’ Cases Too Quickly. Cigna Threatened to Fire Her.

by Patrick Rucker, The Capitol Forum, and David Armstrong, ProPublica
April 29, 2024
 
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…
 
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