How EviCore’s "Denials-for-Dollars" Model is Putting Americans' Health at Risk

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 expose by ProPublica and Capitol Forum shows, is that the medical necessity decisions often were not made by their insurers themselves but were outsourced to companies like Cigna’s EviCore, a major player in the "denials for dollars" industry. 

EviCore generates profits for Cigna and its other customers by reducing access to medical care through a process called prior authorization, in which doctors must seek approval from EviCore before treating their patients. The reporters contend that EviCore’s business model revolves around denying care, a practice that not only jeopardizes patient health but also fattened its — and Cigna’s — bottom line.

At the heart of EviCore's system is an algorithm nicknamed “the dial,” which assesses whether a patient’s treatment should be covered and that can be manipulated to increase the number of denials. It’s all about where the threshold is set: If EviCore decides to boost its denial rate, it simply raises the bar and sends more cases to its in-house doctors for manual review. These reviews are no guarantee of approval, either. The investigation revealed that EviCore’s profit motive often leads to doctors being overruled by an AI system programmed not for patient care but for cost-cutting. The reporters say former employees confirmed that EviCore executives would tweak the system when the company wasn’t generating enough “savings” for its clients—savings that come directly at the expense of patients’ well-being.

Here is an excerpt from the investigation titled “Not Medically Necessary”: Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care:

EviCore markets itself to insurance companies by promising a 3-to-1 return on investment — that is, for every $1 spent on EviCore, the insurer would pay out $3 less on medical care and other costs. EviCore salespeople have boasted of a 15% increase in denials, according to the investigation, which is based on internal documents, corporate data and dozens of interviews with former employees, doctors, industry experts, health care regulators and insurance executives. Almost everybody interviewed spoke on condition of anonymity because they continue to work in the industry.

To accomplish this “3-to-1 return”, EviCore increasingly denies prior authorization requests, with its denial rates in states like Arkansas reaching nearly 20%, much higher than even the 7% denial rate in Medicare Advantage. Insurers don’t explicitly ask for more denials, but their focus on “controlling the spend” leads to this outcome. And it’s not just EviCore. The reporters found that other companies, like Carelon Medical Benefits Management, engage in similar practices, with the same financial incentives to deny care to protect their bottom line.

These profit-driven denials often have devastating consequences for patients like John Cupp, a 61-year-old Ohio man whose doctor requested a heart catheterization to assess his worsening heart condition. EviCore denied it, twice, forcing Cupp to settle for a cheaper, less effective test. 

Cupp’s case is not an isolated incident. In 2022, HEALTH CARE un-covered published an anonymously-authored piece by a former industry executive who ran a prior authorization shop. The executive wrote: 

The other hidden cost of the prior authorization program, one that never seemed to factor into this calculation of return on investment, is patient impact. For every procedure we clinically review and determine to be medically unnecessary, we’ve created an opportunity for confusion and frustration for patients. They likely had no idea that there was an independent arbiter paid by their insurance company to review their doctor’s decisions regarding their health. 

These instances of confusion and frustration are what drive the majority of the bad publicity within the industry, and rightfully so. Without an ability to communicate directly with patients, it is very hard to explain why their doctor may have been mistaken or outdated in their referring practices, or even that their doctor just forgot to submit all the paperwork necessary for a review. As a result, patients are left feeling like a faceless corporation is making their medical decisions and undermining their actual doctors. 

ProPublica and Capitol Forum’s investigation into EviCore sheds light on a disturbing reality: Health insurance corporations increasingly rely on third-party companies with incentives to deny care. 

While prior authorizations were originally intended to prevent unnecessary treatments and overbilling, those third-party companies have twisted the process into a profit-generating machine, one that forces patients and doctors to jump through hoops to secure even the most basic medical services. The result is a system where care all too often is denied to patients who need it most while insurers and their partners reap the financial rewards.