Reports Looks at Hidden Industry Behind Insurance Claim Denials

Friday, October 25th, 2024 -- 12:01 PM

(T. Christian Miller, ProPublica; Patrick Rucker, The Capitol Forum; and David Armstrong, ProPublica) Every day, patients across America crack open envelopes with bad news.

According to a report from ProPublica and The Capitol Forum, yet another health insurer has decided not to pay for a treatment that their doctor has recommended.

Sometimes it’s a no for an MRI for a high school wrestler with a strained back. Sometimes for a cancer procedure that will help a grandmother with a throat tumor. Sometimes for a heart scan for a truck driver feeling short of breath.

But the insurance companies don’t always make these decisions. Instead, they often outsource medical reviews to a largely hidden industry that makes money by turning down doctors’ requests for payments, known as prior authorizations.

Call it the denials for dollars business. The biggest player is a company called EviCore by Evernorth, which is hired by major American insurance companies and provides coverage to 100 million consumers, about 1 in 3 insured people.

It is owned by the insurance giant Cigna. A ProPublica and Capitol Forum investigation found that EviCore uses an algorithm backed by artificial intelligence, which some insiders call “the dial,” that it can adjust to lead to higher denials.

Some contracts ensure the company makes more money the more it cuts health spending. And it issues medical guidelines that doctors have said delay and deny care for patients.

EviCore and companies like it approve prior authorizations “based on the decision that is more profitable for them,” said Barbara McAneny, a former president of the American Medical Association and a practicing oncologist.

“They love to deny things.” EviCore says it scrutinizes requests to make sure that procedures recommended by doctors are safe, necessary and cost-effective.

“We are improving the quality of health care, the safety of health care and, by very happy coincidence, we’re also decreasing a significant amount of unnecessary cost,” an EviCore medical officer explains in a video produced by the company. But EviCore’s cost-cutting is far from coincidental, according to the investigation.

EviCore markets itself to insurance companies by promising a 3-to-1 return on investment, that is, for every $1 spent on EviCore, the insurer would pay out $3 less on medical care and other costs.

EviCore salespeople have boasted of a 15% increase in denials, according to the investigation, which is based on internal documents, corporate data and dozens of interviews with former employees, doctors, industry experts, health care regulators and insurance executives.

Almost everybody interviewed spoke on condition of anonymity because they continue to work in the industry. An analysis of the company’s own data shows that, since 2021, EviCore turned down prior authorization requests, in full or in part, almost 20% of the time in Arkansas, which requires the publication of denial rates.

By comparison, the equivalent figure for federal Medicare Advantage plans was about 7% in 2022. EviCore has several ways to cut costs for insurers. Chief among them is the dial, the proprietary algorithm that’s the first stop in evaluating a prior authorization.

Based on data entered by a doctor’s office, it can automatically approve a request. The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.

Full article here: https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations

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