Companies that help insurance companies deny pre-authorization claims –

KFF survey found that roughly 6 in 10 insured adults have experienced problems while using their insurance. Issues include denied claims, network adequacy, pre-authorization delays and denials. As the investigation shows, this is just not a surprise. A hidden industry makes money by denying doctors’ payment requests, called prior authorizations.

According to a ProPublica investigation, one in every of the important thing participants on this scheme is Evernorth’s EviCore. A ProPublica investigation found that EviCore is owned by the big insurance company Cigna. The largest U.S. insurance companies employ EviCore and supply protection to 100 million consumers.

EviCore apparently uses a synthetic intelligence-supported algorithm that insurance industry insiders call “the shield.” The algorithm system will be customized, which ultimately results in more pre-authorization claim rejections.

What’s even weirder is that EviCore reportedly has some contracts that allow it to make more cash the more it cuts health care spending by insurance companies.

EviCore is just not alone. Another big player is Carelon Medical Benefits Management, a subsidiary of Elevance Health, formerly Anthem. Although the corporate has been accused in court of unlawfully denying legitimate insurance applications, it denies all allegations.

How companies respond

EviCore claims that the approval process ensures that the procedures are protected, obligatory and price-effective.

“We are improving the quality and safety of healthcare, and – by a happy coincidence – we are significantly reducing unnecessary costs,” said an EviCore doctor in the course of the company’s series of webinars.

But based on the investigation, EviCore’s approach is way more sinister than it suggests. EviCore reportedly guarantees a 3-to-1 return on investment, which implies your insurer can pay $3 less for medical care and other costs.

For some perspective, in 2021 in Arkansas, EviCore denied prior authorization requests almost 20% of the time. Medicare Advantage plans denied prior authorization requests about 7% of the time in 2022, based on a ProPublica evaluation of knowledge.

A Cigna spokesperson said on behalf of EviCore: “Simply put, EviCore uses the latest evidence-based medicine to ensure patients get the care they need and avoid services they don’t need.”

The spokesperson added that the corporate uses algorithms in some clinical programs “only to expedite the approval of appropriate care and reduce administrative burdens on healthcare providers.”