When companies like Aetna or UnitedHealthcare want to rein in costs, they turn to EviCore, whose business model depends on turning down paym
"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.
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EviCore is not alone in engaging in the denials-for-dollars business. The second-biggest player is Carelon Medical Benefits Management, a subsidiary of Elevance Health, the health insurer formerly known as Anthem. It has been accused in court of wrongfully denying legitimate requests for coverage. The company has denied all charges. Several smaller companies do the same kind of work.
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Insurers do not make explicit demands for more denials, a former EviCore sales executive said, Instead, they asked about “controlling the spend” — the amount of money paid out on certain procedures, he said. Nor would EviCore always use the word “denials” — they employed circumlocutions like “inappropriate determinations.”
Aetna and Cigna are two of the companies that have requested “high touch” plans — those that would send more cases to clinical review and thus generate more denials, according to the former employee involved in data issues.
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Holding the companies legally responsible for their decisions is also difficult. In 2022, Carelon settled a lawsuit for $13 million that alleged the company, then called AIM, had used a variety of techniques to avoid approving coverage requests. Among them: The company set its fax machines to receive only 5 to 10 pages. When doctors faxed prior authorization requests longer than the limit, company representatives would deny them for failing to have enough documentation. Carelon denied the allegations in court and admitted no fault. A spokesperson declined to comment on the lawsuit."
Read the full article here: https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations
When companies like Aetna or UnitedHealthcare want to rein in costs, they turn to EviCore, whose business model depends on turning down paym
