“Not Medically Necessary”: Helping America’s Health Insurers Deny Coverage

A major health insurance contractor, EviCore, is using algorithm-driven processes to deny medical care to millions of Americans, according to an investigative report by ProPublica and Capitol Forum. The company’s practices are designed to cut costs for insurers, often at the expense of patient access to necessary treatments.

EviCore, owned by Cigna’s Evernorth, manages prior authorization reviews for over 100 million insured individuals in the United States. The company employs an algorithm called ‘the dial’ that adjusts review thresholds to increase the likelihood of denials, a practice confirmed by former employees and internal data. EviCore’s contracts are structured so that the more they reduce healthcare spending, the more profitable they become, with some boasting a 3-to-1 return on investment.

Internal documents and interviews reveal that since 2021, EviCore has denied or partially denied nearly 20% of prior authorization requests in Arkansas, a state that publicly reports denial rates. This is significantly higher than the 7% denial rate observed in Medicare Advantage plans in 2022. The algorithm reviews requests based on data entered by healthcare providers and then scores each request. EviCore can manipulate the thresholds to send more requests for review, increasing the chances of denial. Final decisions are made by doctors, but the process is influenced by the algorithm’s settings.

Medical professionals have criticized EviCore’s guidelines as outdated and rigid, leading to delays and inappropriate denials. Some doctors refer to the company as ‘EvilCore’ due to perceived overreach and cost-cutting motives. EviCore claims its guidelines are evidence-based and routinely updated, asserting that decisions are based solely on medical standards without client bias.

Why It Matters

This investigation highlights how cost-driven denials can delay or block necessary medical care for millions of Americans. It raises concerns about the influence of profit motives in medical decision-making, potentially undermining patient health and trust in the healthcare system. The practice also exemplifies the broader issue of transparency and accountability in insurance-related medical reviews.

Background

EviCore has become a dominant player in the prior authorization industry, managing reviews for a significant portion of insured Americans. Its use of algorithms and cost-cutting strategies has increased scrutiny and criticism from medical professionals and patient advocates. The practice of outsourcing review decisions to profit-driven companies has grown alongside rising healthcare costs and insurer efforts to limit expenditures. Previous reports have documented similar concerns with other companies like Carelon, indicating a systemic issue within the industry.

“They love to deny things. These companies are driven by the desire to cut costs, often at the expense of patient care.”

— Barbara McAneny, former AMA president and oncologist

“We scrutinize requests to ensure procedures are safe, necessary, and cost-effective, based on current medical guidelines.”

— EviCore spokesperson

What Remains Unclear

It remains unclear how widespread the manipulation of the algorithm’s thresholds is across different regions and insurers, and whether regulatory agencies will intervene to curb these practices. The full extent of patient harm caused by denials is also still being investigated.

What’s Next

Regulators and lawmakers are likely to review the practices of companies like EviCore, potentially leading to new rules or oversight. Insurers and review companies may face increased scrutiny, and affected patients might seek legal or legislative remedies to challenge denials. Further investigations and transparency initiatives are expected.

Key Questions

How do insurance companies decide which treatments to deny?

They often outsource reviews to companies like EviCore, which use algorithms and medical guidelines to assess whether treatments are necessary and cost-effective. Decisions can be influenced by cost-cutting incentives.

Are these denials always justified?

Not necessarily. Critics argue that some denials are based more on cost considerations than on medical necessity, leading to delays or denial of appropriate care.

What can patients do if their treatment is denied?

Patients can appeal the decision, often with the help of their healthcare providers. They may also seek legal advice or advocate for policy changes to improve transparency and accountability.

Is this practice legal?

While the use of algorithms in medical review is legal, concerns about transparency, bias, and the influence of profit motives are prompting regulatory scrutiny. The legality of specific denials depends on compliance with existing regulations.