ProPublica and Capitol Forum Expose EviCore by Evernorth and Carelon Medical Benefits Management for Systemic, Methodical, Intentional Denial of Medical Care Needed by Americans
Individuals working at these companies use an algorithm backed by artificial intelligence called “the dial,” to methodically deny medical claim denials | Republished - ProPublica October 23, 2024
Every day, patients across America crack open envelopes and open emails with bad news from their physicians, hospitals, clinics and mental health therapists. Yet another commercial health insurance company has decided not to pay for a treatment that their doctor has recommended and the patient has paid for through premiums.
But commercial health insurance companies don’t make these decisions. Instead, they frequently outsource “medical reviews” to a largely hidden industry that profits by turning down doctors’ requests for payments, known as "prior authorizations." This is part of the Denial of Care business model that remains legal in the United States as of this writing.
Since 1987 we've been reporting on the mechanisms for Denial of Care, only now those tools move at record speed. The biggest player is a company called EviCore by Evernorth, which is hired by major American commercial health insurance companies and processes Denial of Care for 100 million consumers. It is owned by the commercial health insurance giant The Cigna Group.
This ProPublica and Capitol Forum investigation found that the board, senior management team and employees at EviCore use an algorithm backed by artificial intelligence, which some insiders call “the dial,” that is adjusted to process higher rates of Denial of Care.
Because injury, illness and disability are not able to be projected or predicted on balance sheets, at the end of each financial quarter, the dial is usually ratcheted up to ensure shareholder profits at any and all costs.
Increased Denial of Care delivers guaranteed profits.
In a response to questions, a Cigna spokesperson provided a statement on behalf of EviCore. “Simply put, EviCore uses the latest evidence-based medicine to ensure that patients receive the care they need and avoid the services they do not,” it said.
The statement acknowledged that EviCore used algorithms for some clinical programs, but “ONLY to accelerate approval of appropriate care and reduce the administrative burden on providers.”
The statement noted that doctors have the ability to appeal prior authorization denials, and that the company routinely monitors the outcomes “as part of our continuous quality improvement to ensure accurate and timely medical necessity decision-making.”
Some contracts ensure the company makes more money the more it cuts health spending on Members/Patients who are in need of medical care and it issues medical guidelines that doctors have said intentionally delay and deny medical care for patients.
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. Several smaller companies do the same kind of barbaric, cruel and unethical work, which is still legal in the United States of America as of this writing.
PxDx and nH Predict are also tools for Denial of Care. PxDx denies medical care at a rate of 100 denied medical claims per 1.2 seconds, per commercial health insurance company.
Denial of Care is the commercial health insurance business model. How is that working for CEOs, business owners and family owned businesses? Are unhealthy employees and financially-distressed employees good for business?
Read more from the stellar team ProPublica and The Capitol Forum>
Learn more about Senate Bill 1655, which would end these business practices in the context of healthcare.