Dialing for Dollars:
America’s largest insurers hire #EviCore to make decisions on whether to pay for care for more than 100 million people.

“The Dial”:
EviCore uses an algorithm that allows it to adjust the chances that company doctors will screen prior authorization requests,
increasing the possibility of denials.

Lucrative Deals:
Some EviCore contracts are based on how deeply the company can reduce spending on medical procedures.
It tells insurers that it can provide a 3-to-1 return on investment
https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations?utm_source=mastodon&utm_medium=social&utm_campaign=mastodon-post

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

https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations

Email2Toot Robot. Please see entry below for author.

Propublica Article: Denial of Medical Claims

/All,

I am sharing Dr. Linden's post below with permission.

You may also wish to see her opinion article from October 22nd in the
Delaware Bay to Bay News in which she primarily outlines deterioration
to medical care through the intrusion of big business.  She also ties
the future of medical care to election results:
https://baytobaynews.com/stories/linden-improvement-in-health-care-depends-on-election,148362

Michael Reeder LCPC
Baltimore, MD

/~~~~~~~~~~~~~~~~~~~~~
There is an excellent article in yesterday's Propublica about how
companies like Unitedhealthcare, Cigna, and Aetna are using affiliated
companies like Evicore to deny tens of millions of claims a year.

It is unclear in the article whether this includes mental health claims.
However it is relevant to our own medical insurance and that of our clients.

I urge you to read the whole article

https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations

Jill Linden, Ph.D.
psychologist, retired
Delaware

~~~~
#insurance #claims #aetna #unitedhealth #cigna #priorauthorizations
#claimspayments #medicalclaims #EviCore#healthcare #denials
~~~~~~~~~~~~~~~

“Not Medically Necessary”:

Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care

Every day, patients across America crack open envelopes with bad news.
Yet another health insurer has decided not to pay for a treatment that their doctor has recommended.
But the insurance companies don’t always make these decisions.
Instead, they often outsource medical reviews to a largely hidden industry
that makes money by turning down doctors’ requests for payments, known as #prior #authorizations.
Call it the denials for dollars business.

The biggest player is a company called #EviCore by #Evernorth, which is hired by major American insurance companies
and provides coverage to 100 million consumers
— about 1 in 3 insured people.
It is owned by the insurance giant #Cigna.

A ProPublica and Capitol Forum investigation found that
EviCore uses an algorithm backed by artificial intelligence,
which some insiders call “the dial,”
that it can adjust to lead to higher denials.

Some contracts ensure the company makes more money the more it cuts health spending.
And it issues medical guidelines that doctors have said delay and deny care for patients.

EviCore and companies like it approve prior authorizations
“based on the decision that is more profitable for them,” said Barbara McAneny, a former president of the American Medical Association and a practicing oncologist.
“They love to deny things"

https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations

The need for universal healthcare isn’t just about making sure everyone has access to care. It’s also about avoiding the capitalist for-profit system of privatized healthcare.

When healthcare companies are for-profit, they literally exist to make money. Investor needs always take precedence over the needs of people.

https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations

#Healthcare #USA #UniversalHealthcare #EviCore #Capitalism

“Not Medically Necessary”: Inside the Company Helping America’s Biggest #Health Insurers Deny Coverage for Care
—

When companies like Aetna or UnitedHealthcare want to rein in costs, they turn to #EviCore, whose business model depends on turning down payments for #care recommended by #doctors for their #patients.

https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations

#News #Insurance #Algorithm #AI #Healthcare

#aetnasucks

Background:

My wife had an accident this past Thanksgiving day (about three months ago) and hurt her shoulder. She can't raise her arm very high, experiences sharp pain, and that arm is noticeably colder. She wanted to tough it out, thinking everything will fix itself, but she finally went to an orthopedic doctor last week. That doctor can do x-rays and MRIs in-house. They performed an x-ray and determine that the bones were fine and the problem was likely related to the ligaments, but they wanted an MRI to be sure.

The provider had to get preauthorization from #Aetna. Today, after radio silence from everyone, we called to find out what the holdup was. The doctor was waiting to hear back from Aetna. We called Aetna, and they claimed to have no record of the request. It turns out that they have outsourced this to a company called #Evicore Healthcare. We called them. They claim that the authorization can take up to 15 days. For an MRI.

They all suck.