Every day, countless patients in America face unexpected insurance rejections for treatments their doctors recommend. These denials often result from outsourced decisions made by companies profiting from reducing medical coverage.
Patients seeking necessary medical procedures frequently encounter roadblocks, as insurers leverage third-party firms to minimise expenses. These firms, like EviCore, operate quietly yet wield significant influence over healthcare outcomes, impacting one in three insured Americans.
The Rise of ‘Denials for Dollars’
In recent years, the practice of denying medical coverage has evolved into a lucrative business model for companies like EviCore, which is owned by insurance giant Cigna. The company is known for using advanced algorithms, sometimes referred to as ‘the dial,’ to influence coverage decisions significantly. This system allows EviCore to adjust denial rates to maximise profitability, often leaving patients without essential medical tests and treatments.
EviCore markets its services to major insurers by promising substantial savings, with a reported 3-to-1 return on investment. The approach involves scrutinizing requests for medical procedures recommended by doctors, aiming to find those deemed ‘not medically necessary.’ This practice often leads to delays in necessary treatments, impacting patient health outcomes.
The Case of Little John Cupp
Little John Cupp’s experience exemplifies how EviCore’s business model can affect patients. In 2021, Cupp was advised by his doctor to undergo a cardiac exam due to his deteriorating health. However, the procedure was denied twice by his insurance provider, UnitedHealthcare, after the decision was outsourced to EviCore, who deemed it ‘not medically necessary.’
Cupp was a valued member of his family and community. Despite his stature and health issues, he continued to provide for his family, purchasing a new home for his loved ones. The denial of his necessary medical procedure was a pivotal moment in his health journey, forcing his doctor to abandon attempts to secure approval for a crucial heart examination.
Algorithmic Influence
EviCore’s algorithm plays a critical role in its operation. The algorithm evaluates medical requests and assigns a probability score for approval, yet it cannot outright deny requests. Instead, requests with lower probabilities are flagged for further review by medical professionals within EviCore’s team.
The company has the ability to adjust this algorithm to either increase or decrease the number of requests sent for review. This manipulation often leads to an increase in denial rates, earning the company more through its contractual arrangements with insurers. Former employees have disclosed how this system was calibrated to enhance cost savings efforts, often at the expense of patient care. The control over these settings demonstrates a prioritisation of financial interests over patient health.
Medical Community Response
The medical community has expressed significant frustration with companies like EviCore, which often follow outdated guidelines that delay or deny patient care. Many doctors have found these practices obstructive to providing timely and effective treatments to their patients.
Various medical organisations, including ASTRO, have raised concerns about EviCore’s stringent adherence to their guidelines. Despite EviCore claiming that these guidelines are rooted in peer-reviewed research, the medical community has criticised them for not fully accommodating current clinical practices, thereby hindering patient care.
Economic Motivations
EviCore’s business model thrives on its ability to cut healthcare costs for insurers, often without considering the resultant impact on patient care. Their marketing promises substantial cost savings through reduced medical procedure approvals, positioning EviCore as a financially attractive partner for insurance companies.
The company operates under different contracts, some offering fixed rates and others providing monetary incentives to lower spending. This creates a potential conflict of interest, as more denials can lead to higher earnings for EviCore. This model has been criticised as it appears to prioritise fiscal savings over essential medical care, affecting patient health.
Insider Perspectives
Several insiders have revealed the manipulative tactics used to maintain profitability within EviCore. Adjusting denial rates and relying on outdated guidelines are just some strategies that highlight the company’s focus on revenue over healthcare advocacy.
These practices are concerning because they suggest a systemic issue in the health insurance industry where financial incentives drive decision-making processes rather than patient welfare. It leads to questions about the ethicality of profit-driven healthcare systems.
In conversations with former employees, it’s evident that cost control is a primary concern for EviCore and its partners. Adjusting the algorithm’s thresholds to artificially influence denial rates points to a profit-centric approach, suggests one former executive.
The Regulatory Environment
Regulatory oversight of companies like EviCore is relatively limited, with few penalties enforced for discrepancies found during reviews. This lax environment allows such entities to operate with considerable freedom, often to the detriment of patient rights.
Lawsuits and regulatory scrutiny have occasionally spotlighted malpractice in the industry, but significant punitive measures are rare. This calls into question the effectiveness of current regulatory frameworks in ensuring that companies prioritise patient care over profits.
Patient Impacts
Patients are left navigating a complex landscape where essential medical treatments can be dismissed as unnecessary. The burden of securing approval for treatments falls on both patients and their healthcare providers, adding stress and uncertainty to health management.
The case of Little John Cupp highlights the dire consequences of this system, where critical procedures are delayed or denied, potentially compromising patient health. Such cases emphasize the need for increased scrutiny and reform within the healthcare approval systems to better protect patient wellbeing.
Seeking Solutions
Addressing these issues requires reforming the way prior authorization processes are handled by companies like EviCore. Advocating for updated guidelines that reflect current medical standards and improving transparency in denial decisions could alleviate some of the current challenges.
Greater regulatory involvement is also necessary to ensure that companies do not exploit financial models that harm patient care. Moreover, fostering an environment where patient health is prioritized over profits could lead to more equitable healthcare outcomes.
The conversation around healthcare approvals must evolve to include patient advocacy, ensuring that medical decisions are made with the primary goal of enhancing patient health and providing necessary treatments. Only through comprehensive reform can the system hope to balance financial considerations with the true needs of patients.
The current system of healthcare approvals needs comprehensive reform to prioritise patient care over profit. With increased transparency and updated guidelines, the balance between cost-cutting and effective treatment can be achieved.
