In September, the American Medical Association along with two other physician organizations joined a class-action lawsuit against health-care insurer Cigna. The lawsuit alleges that Cigna underpaid health insurance claims filed by providers in the MultiPlan network.¹ 

The suit was brought against Cigna in June by three plaintiffs who had become exposed to balance billing as a result of Cigna’s misconduct. Each of the plaintiffs in Stewart et al. v. Cigna Corporation et al. had internal appeals filed on their behalf, and all were denied. 

MultiPlan is the nation’s largest third-party network company, and it contracts with more than 1.2 million providers in the United States. When providers enter into contracts with MultiPlan, they agree to accept a set percentage of the total billed charges as payment in full and also agree not to hold patients liable for the balance. These participating providers also indirectly contract with Cigna since Cigna contracts with MultiPlan to gain access to their provider network.

The suit alleges that Cigna breached its fiduciary duties, including its duty to honor the written plan’s terms and its duty of loyalty, as the company seems to have put its own economic interests before that of plan member patients. According to the case, Cigna is required to reimburse MultiPlan’s participating providers at the in-network amount, but the insurance company instead applied “lower reimbursement methodology” to pay those providers less, as if they were out-of-network. This left patients “exposed to the threat of balance billing,” says the suit. 

For fully insured plans, Cigna keeps more money by paying less in benefits. For self-funded plans such as those of the class representatives, Cigna’s misconduct enabled it to receive higher administrative fees. “Cigna receives a ‘savings’ fee, payable by its self-funded customers, that is larger when Cigna causes the Plan to pay less for a given claim,” the lawsuit explains. “By paying less than the amount required by the MultiPlan Contract, Cigna increases the amount of ‘savings’ it claims and the resulting fees it receives.”

The lawsuit seeks to represent all who are insured under a Cigna plan governed by the Employee Retirement Income Security Act (ERISA) and who see MultiPlan providers who are indirectly contracted with Cigna.

American Medical Association President Jack Resneck Jr., MD, said in a statement that “Cigna’s misconduct is riddled with conflicts of interest and manipulations that routinely shortchanged payments to MultiPlan Network physicians and interfered with the patient-physician relationship by ignoring the MultiPlan contracts and making incorrect statements to patients about their liability for the unpaid portion of the billed charges.

“Patients and physicians have a right to expect health insurers to uphold their promise to provide fair and accurate payment for medical services,” he continued. He says that by joining the lawsuit as a plaintiff, the American Medical Association hopes to “shed light on Cigna’s misconduct and create remedies so that patients and physicians can look forward to getting what they are promised.”

Cigna could not be reached for comment.

^{1. Stewart v. Cigna. U.S. District Court for the District of Connecticut. Case 3:22-CV-00769. Filed June 10, 2022. https://www.classaction.org/media/stewart-et-al-v-cigna-corporation-et-al.pdf. Accessed September 20, 2022.}

More Bad News for Smokers' Eye Health

There are few health and ocular conditions not impacted by frequently smoking tobacco. In glaucoma, smoking is known to be a risk factor; however, until now, research on the association between smoking and disease progression had been lacking. Findings of the new longitudinal study revealed that higher smoking intensity is associated with faster rates of retinal nerve fiber layer thinning.

The patients included in the investigation had primary open-angle glaucoma, at least three years of follow-up and five visits with OCT scans. There were 466 eyes of 314 patients in the analysis, all with follow-ups between 6.4 and 6.7 years. Smoking intensity was calculated as packs per year as reported at the baseline OCT visit.

The researchers noted that 39 percent of the patients reported a history of smoking and that the average smoking intensity was 16.5 packs per year. The data showed that greater smoking intensity was significantly associated with faster RNFL thinning (-0.06 µm/year per 10 packs/year increase) after adjusting for all other factors including alcohol consumption, BMI and race, none of which showed an association. They wrote in their paper, “Specifically, when smoking intensity is greater than eight packs per year, smoking intensity was associated with faster RNFL thinning in patients with glaucoma.”

The patients who had a slower rate of RNFL thinning over the study period smoked a mean of 15.1 packs per year, while those with a moderate to fast rate of thinning had a mean smoking intensity of 24.3 packs per year. In patients who smoked previously, 20.7 percent were classified with at least a moderate rate of RNFL thinning. Considering this finding, the researchers suggest it would be helpful if future studies focused on whether smoking cessation can reduce glaucoma.

Because patients who smoke may be at higher risk of faster and irreversible progression potentially leading to vision loss, the researchers concluded, “As with other risk factors for glaucoma, the smoking status of a patient can help guide both the frequency of monitoring and the glaucoma therapy.”

^{Nishida T, Mahmoudinezhad G, Weinreb RN, et al. Smoking and progressive retinal nerve fiber layer thinning in glaucoma. Br J Ophthalmol. September 13, 2022. [Epub ahead of print].}



Strokes and the Prevalence of Ocular Disease

A cross-sectional study was recently conducted to better understand the relationship between stroke and ocular disease. Significant associations between visual impairment and major ocular disease with stroke were observed in this national study population. The study included 4,570 participants in the 2005-2008 National Health and Nutrition Examination Survey.

With an odds ratio of 5.54, ocular disease was associated with stroke, most notably in the form of cataract (30.8-percent prevalence among stroke patients vs. 13.4 percent without), AMD (19.6 vs 7.2 percent) and diabetic retinopathy (26.6 vs 11.6 percent). Following adjustments for age and gender, an odds ratio of 9.61 was observed among stroke patients with diabetic retinopathy. Additionally, the study authors reported odds ratios for mild to moderate and severe visual impairment of 6.79 and 9.46, respectively, after adjusting for age and gender.

The study authors noted that the associations were limited to mild visual impairment, mild-to-moderate and severe visual impairment and any ocular disease. The data also revealed significant associations between diabetic retinopathy and any ocular disease in diabetic participants. The researchers identified a close relationship between stroke and mild-to-moderate and severe visual impairment among individuals with hypertension.

“Despite impaired central vision, which is the most common visual impairment in stroke patients, eye movement disorders, visual field loss and visual perceptual disorders are also usually found among stroke patients, and most patients have a combination of several visual problems,” the authors wrote in their paper to be published in the journal Eye.

“Our cross-sectional study shows stroke is associated with increased prevalence of ocular diseases,” the study authors noted. “These findings highlight the importance of ocular screening among stroke patients and potential common pathogeneses underlying these conditions.”

^{Li HY, Yang Q, Dong L, et al. Visual impairment and major eye diseases in stroke: a national cross-sectional study. Eye. September 21, 2022. [Epub ahead of print].}