In case you missed it, a new ProPublica investigation sheds light on how corporate insurance companies “often outsource medical reviews to a largely hidden industry” that grows insurers’ profits by engineering the prior authorization review process to increase how often requests are reviewed by medical professionals and, in turn, denials overall.
EviCore, a company owned by corporate insurance giant Cigna, “works with more than 100 insurers across the country” and manages prior authorization requests for these insurers covering 100 million consumers, or 1 in 3 insured Americans. Insurers “outsource prior authorization decisions” to EviCore, which then uses “an algorithm backed by artificial intelligence, which some insiders call ‘the dial,’ that it can adjust to lead to higher denials.” ProPublica found that insurers chose to work with EviCore specifically because its ability to minimize claims payouts led to greater profits.
According to ProPublica, EviCore’s sales pitch to insurance companies can be summed up as “denials for dollars.” The company offers a “3-to-1 return on investment,” promising to reduce claims payouts by $3 for every dollar spent on EviCore’s services. “EviCore salespeople have boasted of a 15% increase in denials.” Indeed, in Arkansas, in 2021, EviCore denied a full 20% of the prior authorization requests that it handled — nearly triple the normal rate of denials for Medicare Advantage plans.
These profit-seeking tactics can have catastrophic consequences for patients’ health and access to medical care. In central Ohio, the physician of a patient named Little John Cupp sought prior authorization two separate times for catheterization to examine Cupp’s arteries. Cupp’s corporate insurer, UnitedHealthcare, “outsourced the decision to EviCore,” which overruled Cupp’s doctor and denied both requests. Tragically, Cupp died of cardiac arrest a few months later. When ProPublica asked four cardiology experts to review Cupp’s medical situation, three of the four said his doctor’s request was appropriate. One expert explained the catheterization was “certainly necessary.” One said it might have saved Cupp’s life.
ProPublica found that EviCore’s contracts give the company strong incentives to deny as much patient care as possible. In some arrangements, EviCore assumes responsibility for paying claims that are not denied in exchange for getting to keep any savings it can secure beyond insurers’ standard expenditures. A former insurance industry executive interviewed by ProPublica said, “That to me is troubling. It suggests that the claim settlement procedure is not objective, right?” said former California insurance commissioner Dave Jones. He added, “It calls into question everything that’s occurring.” The entire business model of these “risk contracts” revolves around overruling doctors’ requests as often as possible and maximizing denial rates for patient care.
As ProPublica reports, EviCore’s guidelines for approving or denying prior authorization requests are often extremely inconsistent with the recommendations of medical professionals. For instance, a 2023 academic study of EviCore’s criteria for approvals on imaging of the lower spine for chronic pain patients found the company’s criteria to be deficient.
ProPublica also reports that EviCore’s largest competitor, Carelon, spent $13 million settling a 2022 lawsuit over accusations that it used a variety of techniques to improperly avoid approving coverage requests — including setting its fax machines to receive only 5 to 10 pages so that it could deny requests longer than the limit for failing to have enough documentation.
Insurers frame prior authorization as a tool to reduce wasteful medical spending and unnecessary procedures. But as ProPublica’s reporting confirms, it has ballooned into an entire industry that gives for-profit corporations financial incentives to deny necessary patient medical care. “The fact that these big companies focused on profits can play all these games is quite disturbing to me,” said Martin Lustick, a former insurance executive and the author of a book on industry practices interviewed by ProPublica. “They know the more reviews they do, the more denials they get.”
It’s time to hold corporate insurers accountable for abusing prior authorization, refusing to pay for medically-necessary care and putting profits over patient’s health.