Watch Cigna Like A Hawk!
CALIFORNIA -- I am retired, but my wife still works for the University of California, for health benefits. It's a good thing I'm retired, because since we switched from Blue Cross PPO to Cigna Open Access at the beginning of the year, keeping on top of them has become a full-time job.
We made the switch because, on its face, Cigna was a better deal than Blue Cross. The premiums were more than $100/month less and the maximum out-of-pocket expense was half of Blue Cross's. In addition, prescription drugs counted against the deductible, and co-insurance payments and once the deductible was met and the maximum co-insurance limit reached, Cigna paid for them 100 percent. Plus, the university sets aside $1,500/year, per household for medical expenses. You have to exhaust that amount before your deductible kicks in. If you don't spend it all, the remainder rolls over to the next year. The final deciding factor for us was that Cigna seemed to cover all the doctors we were already seeing, including specialists I'd already been seeing at Stanford. And if necessary, we could have access to other specialists at UC San Francisco, another top teaching hospital in our region. For the most part, this plan has delivered as promised, but only with a lot of oversight on my part.
I have had a lot of experience with Cigna in the first year because, scarely a week into '08, I fell on ice and severely fractured my hip. This led to surgery, two weeks post-op hospitalization, one week of in-patient rehab, seven weeks of home confinement and then follow-up physical therapy (still continuing). The biggest problem with Cigna throughout this period has been numerous disputes over whether providers are "in-network."
All of the providers I've been seeing locally work for a single medical group which is under contract with Cigna. Yet Cigna initially ruled several of them as being out of network and paid accordingly (paying at 60 percent instead of 80 percent, and not counting the co-insurance toward our in-network, out-of-pocket cap). In one case, the doctor was considered out of network because Cigna had his physical address instead of his actual billing address (the medical group's). In another case, they simple didn't have the doctor's name in their database. I was unable to straighten this out over the phone with Cigna's representatives and finally had to take Cigna's EOBs into the medical group's billing office, where I sat down with a real person who was ultimately able to resolve the issue. In a third case, Cigna said the physical therapist I was seeing was not in network, even though she was employed at a facility operated by the same medical group. Once again, I had to personally go to the medical group's office to get this problem resolved. Once it was straightened out, however, it still wasn't fixed! Despite the fact that Cigna paid three subsequent physical therapy bills correctly as in-network claims(and at 100 percent, our out-of-pocket cap having long since been met), they are at this writing still refusing to pay in full the first two -- resubmitted -- physical therapy bills, saying they'd already been paid. Well, yes, Cigna did pay them, but incorrectly, treating them as being out of network. Yet in denying the resubmitted claims, they now showed the physical therapist provider as being in network. It's enough to make one's head spin. I didn't even bother to call Cigna about this, knowing it would be a waste of time. I went back to the medical group billing office, handed them the EOBs and said, "They're at it again. Please take care of this."
Another issue I had with Cigna during this time was related to ambulance services. They don't seem to consider any ambulance companies, public or private, to be in their network. So they always treat the initial claims as out of network. I had to call them on each one, and I had several, to point out that these were emergency services; it wasn't like I could choose an ambulance company when I was lying in the street, etc., etc. They finally did pay the bills appropriately.
My bottom line conclusion: Cigna claims processing is incredibly sloppy and I think it's willful on their part. I believe they're betting that most subscribers will be too busy to pay close attention to their EOBs and will just pay whatever Cigna says they owe. That way Cigna gets out of paying what it owes, both to subscribers and providers. If you can make this plan work for you, it's good, but that will require an inordinate amount of work on your part. Subscriber beware!