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A recent article in Healthcare Business Today did an excellent job summarizing the current state of affairs in the independent primary care medical practice. I encourage everyone to read it.
Over the past year there have been posts asking if doctors are overpaid or if we are the college tuition bank for the doctor’s children. These are valid questions and I provided a lengthy reply sharing my thoughts regarding the college tuition bank post.
I have thought a lot about these previous posts as I continue to work two days a week dealing with the aggravation of electronic medical records, coding, and insurance company nonsense. I don’t need to work but I still enjoy helping our patients with their healthcare needs and I also try to help them navigate the health insurance challenges.
It is interesting to me that there seems to be little interest in whether or not insurance company executives or hospital administrators are overpaid or if we are the college tuition bank for their children.
While talking to our family medicine practice manager last year, I noticed stacks of documents on her desk. Since everything is done online these days, it is rare to see stacks of documents on the desks of our office staff anymore.
When I asked her what they were, she told me that they were hard copy insurance claims that had not been paid since the first of the year. The estimated amount for the unpaid claims was over $60,000 at that time and this had been going on for about seven months.
I was told that the hard copy claims were because the insurance company kept denying the claims that were submitted online. Even though our staff had made sure that the online claims were accurate, they were still not being paid. Consequently, the hard copies were printed and triple checked and submitted again.
The insurance company involved was Cigna.
Since we are an independent family medicine practice, every dollar counts in order to keep the lights on, staff paid, and other daily necessities. We do not rely on a large hospital system to cover the cost of unpaid insurance claims for over seven months.
Furthermore, there is not an endless budget to pay staff to keep checking and resubmitting insurance claims. I know this is part of the Cigna (and any insurance company) plan. Delay long enough hoping that offices quit submitting claims for the money owed to them.
Consequently, our physicians go unpaid for some months due to this shortfall and because they are looking out for the staff. Unlike many other medical specialties, primary care providers do not always have the luxury of fancy cars or multiple vacation homes.
This problem with Cigna is not just isolated to our group. Medical offices around the country have been shortchanged by Cigna for years. Cigna claims it was due to a glitch in their software, but the problem has persisted since 2022.
Based on this lack of payment, Cigna had a class-action lawsuit filed against it by patients and physicians in 2022. However, a federal judge ruled in 2024 that neither the American Medical Association or other organizations representing physicians can be a part of the lawsuit.
I am unable to find any online information regarding a new class-action lawsuit being filed by patients against Cigna.
Gee, who is going to win when the dust settles? The lawyers overseeing the class-action lawsuit. Who is going to lose? The patients and independent medical practices.
My father was a general practicioner who had a solo practice until he died prematurely of a stroke at age 65 in 1987 (I remember going on a few evening house calls with him when he used a spot light to identify patients house addresses). More than 1,000 people, mostly his patients, attended his funeral. Unfortunately, I think it is clear that the independent medical practices like his will soon be history.
When I moved to NYC in 1994, I was able to find an excellent family solo practicioner. However, after ~20 years he decided dealing with insurance companies was too expensive and stressful so he joined the NYU medical system. While his missed his independence he said that he was surprised to find that being relieved from much of the stress he experienced in private practice had rejuvenated his enjoyment of being a physician.
Scott, I appreciate you writing about your experience as an independent primary care physician. It was eye opening to me and I learned something. What you wrote definitely is part of the mission of HD, at least IMO. Chris
If Humble Dollar is supposed to be about personal finance and how to manage your money – I don’t see the relevance of independent physician offices and their struggles with insurance companies.
Can we stick to the mission?
Interesting perspective. How about this comparison. I have a patient with ongoing shoulder pain and an MRI of the shoulder is needed. If I order it through one of the local hospitals it is going to cost maybe $2,500 or more. If I order it through an independent imaging center it is going to cost $700 and is reviewed by the same radiologists as the hospital.
Quite a savings of $1,800 to either the patient or their health insurance provider.
However, if there aren’t any independent primary care physician offices and only hospital owned offices, a patient will not be able to use the local independent imaging center. The hospital system will require us to only order the MRI through their more expensive radiology department. This is already happening with hospital owned medical practices and has for years.
Seems to me that these facts can very much affect personal finance.
My wife has had numerous MRIs, scans, etc. different doctors in different groups write the script, but then she makes the appointment at location of choice. They send report to doctor and we take CD to give to any other doctor as needed.
Well, those type of issues have a direct impact on your health care dollars.
My two largest expenses in retirement are taxes and medical care. I appreciate learning more about the black box of medical insurance.
If you are adventurous, you might want to read the healthcare section of my blog which reflects my 50 years managing health insurance and health benefits. https://quinnscommentary.net/category/healthcare/
There is no black box. It is straight forward- too complex – but not complicated.
Unfortunately most people don’t want to recognize the truth that the use of and cost of health care drives premiums.
I hear you Marion. Maybe do what I do, and just click past the posts that don’t interest you. There’s a lot of content here; it’s okay to blow past some of it.
There is also enough great financial stuff in the archives to keep you busy for a long time. Most anything from Grossman and Jonathan is worth checking out.
I appreciate that Dan – I commented on it because I don’t think this article would have gotten past Jonathan’s desk.
Quite the contrary Marion. Jonathan asked me to write an article about which Medicare option I chose in 2023. Here is the link: https://humbledollar.com/2023/05/time-to-decide/.
FYI..Jonathan liked my perspective and encouraged the articles/posts that I have done in the past. As Dan suggested, just bypass any of my future posts if they are so bothersome to you.
Insurance companies generally do not make data on denied claims available to the public. However, an analysis based on federal health insurance marketplace data found the following health insurance denial rates by company:
https://www.wallaceinsurancelaw.com/health-insurance-denial-rates-by-company/
Why is the real question. Many denials are the result of claim errors. Many are reversed. Plus keep in mind, surveys of physicians estimate up to 25% of health care is duplicative or unnecessary.
If you think premiums are unaffordable now, imagine if claims were paid with no questions asked.
I don’t doubt what you are saying, but there must be more to it. If you think about it, it is not even logical from a business sense.
Employer and union groups wouldn’t put up with such tactics. Patients will hear complaints from providers, etc. it’s just a losing strategy for the business.
Plus they risk losing the ability to sell insurance in a given state if they are investigated and an intentional non payment strategy is proven.
What I don’t understand about your article is your sole focus on Cigna. Are we to assume that you don’t have any problems with all of the other insurers?
As I detailed in the sixth paragraph of my post above, Cigna had not paid our practice over $60,000 in seven months. I am not aware of any other health insurance company withholding the payment of claims for that length of time. In addition, when I dug deeper into the topic, I learned that Cigna was doing the same thing to healthcare providers all over the country. Please review the following link that I referred to in my post: https://www.dmagazine.com/healthcare-business/2024/04/local-physicians-say-cigna-owes-them-thousands-and-will-not-stand-by-with-the-lack-of-action/
My perception of this article is that it calls for the readers to stop the “Overpaid” accusation, and to support the independent medical practices. It re-opened the argument that the author had back in April 2025 as a response to another author’s personal story.
This forum has made it clear that most readers found the US healthcare system to be dysfunctional. Reopening the call to stop accusations is not likely to be move the perception one way or another, at the cost of more debates. In my opinion, “overpaid” accusation is NOT a financial debate, but an emotional reaction by frustrated healthcare recipients against the system, and the practitioners are the face of such system. Sympathetic listening would be far more satisfactory to both sides than defensive posture with facts and figures.
The value of independent medical practice should be apparent to both the providers and the beneficiaries without showing the ugly side if bureaucratic insurance snafu, which is beyond the concern of the people already distressed by the illness and financial implications. There are creative solutions that stay quite far from this forum.
I do find the educational value in this article. But my head hurts with a reflection why vast numbers of providers are burn out.
Sorry for the headache. Maybe try an ibuprofen every 4 to 6 hours. No cost for that advice 🙂
We can agree to disagree. I am not reopening anything nor am I demanding anyone stop the “overpaid” accusation. The “overpaid” accusation is something that needs to be debated with “sympathetic listening” as does our whole healthcare and insurance system.
All I am trying to do is give a different perspective by sharing every day life reality in primary care. I would think most reasonable people would like to hear the other side of the story, especially since I have not seen many posts from healthcare providers on HumbleDollar regarding this topic.
I would never dream of telling anyone to stop defending yourself when falsely accused.
The question of overpaid or not directly relates to insurance premiums and Medicare taxes and certainly is a financial matter, perhaps one of the most misunderstood, just ask someone who wants to retire before age 65.
Cigna and other insurers drain $ from healthcare spending and add no value.
I disagree with that. I have many stories from experience where the insurer added value in reviewing claims. I often had disputed claims reviewed by a third party and often learned some interesting things about the care being provided or proposed.
They also absorb the risk. Keep in mind that about 60% of workers are in self-insured plans where the insurance company/claim administrator has no financial stake in claims, but only processes claims according to the employer plan.
The bulk of healthcare spending is on healthcare while the net profit margins for health insurers are among the lowest for any industry, generally lower than even regulated utilities.
No matter the system, somebody has to process and monitor claims.
I know from working with patients, physicians and insurance from the benefits/claim side there are two sides to these stories. If CIGNA is that bad, why not just no longer accept their coverage?
Folks, I don’t know why Dick received so many down votes with this comment. His question is perfectly legitimate in my opinion.
From my limited personal experience, a lot of docs and dentists are dropping Cigna.
I know this sounds like an obvious solution. In fact, many healthcare providers, labs, and imaging centers in our area have quit accepting the Cigna Medicare Advantage plan known as Cigna HealthSpring. It is not the fault of the patient that Cigna is so hard to work with. They don’t know until they try to use it. I am willing to bet the brokers pitching Medicare Advantage plans every fall do not always explain these problems to their future clients.
Another factor is that many of our patients work for local government, hospitals, or school systems and Cigna is their default insurance carrier (this is regular health insurance and not Medicare Advantage). In many cases, we have been seeing these patients and their families for decades.
As Dan stated, we have a lot of loyalty to our patients and by our patients. Unfortunately, I think the writing is on the wall. The independent healthcare providers are going to continue to disappear and all primary care offices will eventually be owned by large hospital systems, private equity firms, or health insurance companies. Then they can argue with each other about reimbursement.
Unfortunately, I think you are right. The solo practice can’t survive. I have asked in scores of doctor’s offices (literally) the best and worst insurance to deal with. At least in our area, the worst is Aetna and the easiest Medicare – presumably because it’s basically no questions asked up front.
MA is a whole different animal which, in my opinion, should not exist.
When I decided on Medicare Advantage, I made it a point to ask my providers at the University of Washington and Fred Hutch Cancer Center which company was the easiest for them to work with in terms of getting claims approved and processed. Their reply was United Healthcare, which has an odious national reputation but has so far turned out to be excellent.
With regards to insurance agents, I’ve found good ones do share information on problems with companies, because they hear back loudly from their clients if they steer them to an unresponsive insurer. But not all agents are good at their jobs.
Dick, if it was only happening to this provider, I would suspect issues with the way claims were coded and submitted, but the class action lawsuit suggests that the insurance company may be at fault.
If I was the provider, I would be torn between dropping CIGNA and loyalty to my patients using the company.
I don’t know anything about the Gigna situation, but I do know that anything less than claims being paid without question results in complaints from both patient and provider. I also know MA plans can be overly aggressive, but that is the nature of managed care.
We don’t like the “interference” but we also don’t like the premiums that result without it.
Back in the early 1960s I helped the US Chamber of Commerce oppose Medicare. These days I see M4A as the only solution that can come close to being fair, but with higher payments to providers than currently which are woefully inadequate.
I can say with certainty that the recent idea proposed is nonsense.
What’s amazing about the recent proposal is that there are doctors in Congress and this administration who are actively supporting this nonsense. Do they really not know how healthcare works or we being gaslighted? Me thinks the latter.
Without a doubt, insurance companies have to perform due diligence. Insurance companies are constantly the target of fraud. You are correct that neither you or I can judge what is going on with this CIGNA situation.
I’m glad you came around to the M4A conclusion. As to the most recent idea you reference; it would be a complete and total failure and waste of taxpayer money.