What kinds of complaints warrant a formal investigation?
In general, any complaint that would warrant disciplinary action if
substantiated (e.g., sexual misconduct, gross negligence and/or
incompetence, etc.) is referred for investigation. Other kinds of
complaints may also require a formal investigation. These include physician
impairment, unprofessional conduct and unlicensed practice issues.
I thought similarly when reading the part of the article where the legal team said that Cigna's policy wasn't illegal. Maybe it isn't against any laws for the company to do it, but isn't it unethical for doctors to do it? If the law requires that licensed doctors be the ones to review the claims, maybe the most effective way to change this practice is for medical boards to start sanctioning doctors who do this.