“Not Medically Necessary”:

Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care

Every day, patients across America crack open envelopes with bad news.
Yet another health insurer has decided not to pay for a treatment that their doctor has recommended.
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"

propublica.org/article/evicore…

EviCore, the Company Helping U.S. Health Insurers Deny Coverage for Treatments

When companies like Aetna or UnitedHealthcare want to rein in costs, they turn to EviCore, whose business model depends on turning down payments for care recommended by doctors for their patients.

^ProPublica