"Not Medically Necessary": Helping America's Health Insurers Deny Coverage
4 hours ago
- #prior authorization
- #medical denials
- #health insurance
- EviCore, owned by Cigna, is a major player in the prior authorization review industry, used by insurers to decide payment for over 100 million people.
- EviCore uses an adjustable algorithm called 'the dial' to increase manual reviews, leading to higher denial rates for coverage requests.
- Some contracts incentivize EviCore to cut costs, with promises like a 3-to-1 return on investment for insurers.
- Medical groups complain that EviCore's guidelines are outdated and rigid, causing inappropriate denials or delays in care.
- A case study involving patient Little John Cupp illustrates how EviCore denials impacted his heart treatment; he died after being denied a catheterization.
- Insurers and state Medicaid programs hire EviCore to control spending, but critics argue the system prioritizes profits over patient care.
- EviCore's practices include 'risk contracts' where it profits from reducing claim payments, and manipulating review thresholds to meet savings goals.
- Regulatory oversight is minimal, with few penalties for violations, and legal challenges against these companies face hurdles in court.
- The 'sentinel effect' describes how doctors reduce prior authorization requests due to EviCore's presence, potentially limiting necessary care.
- The investigation highlights broader industry issues, including similar practices by other companies like Carelon, and calls for scrutiny of insurance denial systems.