Every day in America, thousands of patients get notices from their health insurers that the treatments their doctors say they need will not be covered because it is not, in the opinion of the insurance company, “medically necessary.” What they likely don’t realize, as a new
Everyday the UR department nurses send 9 /10 authorizations to their medical directors who never see the clinical. Depending on the metrics the company has set for the staff the company is more interested in getting those diagnosis that are on the escalation list or deemed a 1 day or 2 day stay and even longer stays not meeting the medical necessity criteria that only looks at one diagnosis and not at the overall condition of the patient. The reviews are typed up by someone who may not even have any clinical experience and is in a hurry to get cases higher up. Many are nurses who don’t have a clue about clinical or catastrophic diagnosis and leave out key information.Now the plans are outsourcing overseas to new grads and who knows what they been told to do as these individuals usually are not licensed in the US. They are hidden by fancy names like clinical coordinator. Than you have the health plan telling everyone just put in the bare bone minimum documentation. And everyone knows that ethically something wrong but if those who have the money and the power can’t do anything but write about the subject what can the employee do.
Going through this right now, as Evicore has deemed the breast MRI my physician ordered not medically necessary. Every breast specialist/mammographer I've ever been treated by has stressed the need for a breast MRI due to the extreme density of my breasts...but not the physicians at Evicore! In the end, I'll be paying out of pocket for the MRI--at a self-pay rate that is significantly cheaper than what I would've owed had Cigna authorized the procedure (which is also f**ked up).
This just makes me sick to my stomach, reading about this callous, heartless crap! (But I'm sure that that "sickness" would be denied treatment by EviCore - ha!) Man-oh-man, is our so-called "healthcare" system completely and utterly broken!
Why should this report surprise anybody. Insurance companies are in the business of generating funds and income and money and they are not really in the public interest unless they are prodded to do so. As corporate entities their obligation is to their shareholders not to the patients. I understand this because I am both a doctor and an accountant
Pro se will kill them. HHS, OCR, EEOC, letters, these people are stealing our money and have such a great preventative plan, our life spans are deteriorating. Greed, avarice and heinous back door deals . These dudes include CMS, SAMSHA, ect.
Outsourcing to Cigna’s Evicore is pure EVIL and unconscionable. If Congress is unaware of how patients of Medicare (dis)Advantage are systematically being denied care and end up sicker or dead is clearly a Human Rights Abuse. This is not how to save money off the backs of US Taxpayers and patients lives. This is no different than Planned Genocide. Election time draws near. Time is up for those Members of Congress and the US Senate who are woefully ignorant of what is going on.
I am ashamed of how low this Nation has devolved. Where is the dignity of those serving allegedly as our Representatives and leaders in Government.
Almost a year ago, EviCore reached out to our hospital touting their automation and connections to payors and pushing us to sign up to get a real time data feed from our EMR to the payors through them. They sold it as a way to speed up PA's. We didn't sign (thankfully). Even though you still have to go through them (manually) for PA's, the data sharing looks like it would've been a disaster
Everyday the UR department nurses send 9 /10 authorizations to their medical directors who never see the clinical. Depending on the metrics the company has set for the staff the company is more interested in getting those diagnosis that are on the escalation list or deemed a 1 day or 2 day stay and even longer stays not meeting the medical necessity criteria that only looks at one diagnosis and not at the overall condition of the patient. The reviews are typed up by someone who may not even have any clinical experience and is in a hurry to get cases higher up. Many are nurses who don’t have a clue about clinical or catastrophic diagnosis and leave out key information.Now the plans are outsourcing overseas to new grads and who knows what they been told to do as these individuals usually are not licensed in the US. They are hidden by fancy names like clinical coordinator. Than you have the health plan telling everyone just put in the bare bone minimum documentation. And everyone knows that ethically something wrong but if those who have the money and the power can’t do anything but write about the subject what can the employee do.
Going through this right now, as Evicore has deemed the breast MRI my physician ordered not medically necessary. Every breast specialist/mammographer I've ever been treated by has stressed the need for a breast MRI due to the extreme density of my breasts...but not the physicians at Evicore! In the end, I'll be paying out of pocket for the MRI--at a self-pay rate that is significantly cheaper than what I would've owed had Cigna authorized the procedure (which is also f**ked up).
Wow, they just need to stick an “L” between the I and C in their name
This just makes me sick to my stomach, reading about this callous, heartless crap! (But I'm sure that that "sickness" would be denied treatment by EviCore - ha!) Man-oh-man, is our so-called "healthcare" system completely and utterly broken!
Why should this report surprise anybody. Insurance companies are in the business of generating funds and income and money and they are not really in the public interest unless they are prodded to do so. As corporate entities their obligation is to their shareholders not to the patients. I understand this because I am both a doctor and an accountant
Sue these fools or press criminal charges.
Pro se will kill them. HHS, OCR, EEOC, letters, these people are stealing our money and have such a great preventative plan, our life spans are deteriorating. Greed, avarice and heinous back door deals . These dudes include CMS, SAMSHA, ect.
Outsourcing to Cigna’s Evicore is pure EVIL and unconscionable. If Congress is unaware of how patients of Medicare (dis)Advantage are systematically being denied care and end up sicker or dead is clearly a Human Rights Abuse. This is not how to save money off the backs of US Taxpayers and patients lives. This is no different than Planned Genocide. Election time draws near. Time is up for those Members of Congress and the US Senate who are woefully ignorant of what is going on.
I am ashamed of how low this Nation has devolved. Where is the dignity of those serving allegedly as our Representatives and leaders in Government.
Almost a year ago, EviCore reached out to our hospital touting their automation and connections to payors and pushing us to sign up to get a real time data feed from our EMR to the payors through them. They sold it as a way to speed up PA's. We didn't sign (thankfully). Even though you still have to go through them (manually) for PA's, the data sharing looks like it would've been a disaster