“Denials for Dollars”: How Health Insurers and Their Partners Can Decide Your Care

Every day across America, patients open letters bearing bad news. An MRI for a childhood injury, a grandmother’s cancer procedure, or a truck driver’s heart scan—all can be denied by health insurers. However, the responsibility for many of these decisions actually belongs to another dedicated industry profiting from denial of care, sometimes known informally as the “denials for dollars” business.

The largest company in this industry is EviCore, a subsidiary of Cigna, which oversees the health coverage of 100 million people, or about one in three insured Americans. EviCore promises insurers a 3-to-1 return on investment: every dollar they spend with EviCore translates into $3 saved on medical payouts.

But the increase in profits often come at a steep cost to patients.

An Algorithm That Could Decide Life and Death

EviCore utilizes AI (artificial intelligence) to review treatment requests. Known internally as “the dial,” the algorithm helps to detect and determine which requests will be flagged for further scrutiny. Adjusting the algorithm’s thresholds allows EviCore to decrease or increase the number of denials. A lower threshold means more requests are approved; a higher one sends more cases for manual review, increasing the likelihood of denial.

“We could control that,” admitted a former EviCore technology executive.

“That’s the game we would play.”

Some doctors and medical experts have criticized EviCore’s guidelines as rigid, outdated, and cost-focused, resulting in neglectful or delayed care. Some frustrated physicians have resultingly nicknamed the company “EvilCore.”

“Insurance has too much say over something that can save your life,” said Chris Cupp, the daughter of John Cupp, a welder from Ohio and one such patient affected by Evicore. Mr. Cupp died of cardiac arrest after being denied coverage twice for a heart catheterization by UnitedHealthcare, who outsourced the decision to EviCore.

Profit Over Patients

EviCore’s business model thrives on cutting costs. In some contracts, insurers pay a flat fee for EviCore’s services. More lucrative are “risk contracts,” where EviCore keeps a portion of the money saved by reducing claims. The more procedures denied, the more they profit.

Doctors say these practices discourage them from even requesting care, a phenomenon known as the “sentinel effect,” EviCore executives also have acknowledged that many physicians stop submitting authorization requests, principally due to the arduous process and frequent rejections.

However, the issue extends beyond EviCore. Competitors like Carelon (formerly AIM) face similar accusations of wrongful denials. While prior authorizations (pre-approved treatment options by insurance) were intended to prevent unnecessary or fraudulent treatments, the system increasingly prioritizes financial savings over patient health.

The issue raises important ethical questions: Are these companies making objective medical decisions—or playing a numbers game with lives on the line?

So far, state and federal regulators have imposed minimal penalties for such practices. Insurers argue that these systems help control waste and reduce unnecessary procedures, but critics, including former insurance executives, call the denials manipulative, profit-driven, and ultimately harmful.

As debate continues, the question looms: How many more lives will be affected in the name of savings?

The U.S. healthcare system is undergoing significant changes due to these legal challenges and regulatory interventions.

If you want to learn more about filing a claim for a civil personal injury matter, reach out to our team here at Herd Law Firm at 713-955-3699 or charles.herd@herdlawfirm.com for more information!

12/2/2024

Source: EviCore, the Company Helping U.S. Health Insurers Deny Coverage for Treatments — ProPublica