On the heels of recent allegations against MultiPlan regarding questionable reimbursement practices, new questions are emerging about EviCore’s proprietary algorithm-based system for prior authorizations.
According to a ProPublica and Capital Forum investigation, EviCore, which is owned by Cigna and manages prior authorizations for insurers like Aetna, Blue Cross Blue Shield, Cigna and UnitedHealthcare is adjusting the algorithm that screens authorization requests submitted by providers for medical procedures, to increase the probability of a denial which yields more money for both the insurer and EviCore.
The report states EviCore’s rate of denials promoted by its salesforce is 15%, which is significantly higher than the 7% denial rate attributed to federal Medicare Advantage plans.
The purpose of prior authorizations has been twofold: (1) to protect patients from providers who may recommend unnecessary or potentially harmful treatments, and (2) to protect insurers from providers who overbill for services.
While insurers purportedly use EviCore’s services to ensure safe and necessary medical treatment, it also offers contracts that focus on “controlling cost,” including, in some cases, a “shared savings model” between EviCore and the insurance companies.
Although different, the business models employed by MultiPlan and EviCore reveal a shared trend: third-party vendors increasingly prioritizing revenue over patient-centered care, often using technology to enforce cost-saving strategies that can disrupt timely access to healthcare. The American Hospital Association (AHA) recently called for an investigation into Multiplan, citing unfair reimbursement practices, and EviCore’s automated denials are now under similar scrutiny for their effects on patient care and provider trust.
The reliance on technology for profit at the expense of patient care points to a troubling direction in healthcare. Rather than enhancing access and quality, these tools are increasingly being deployed to optimize revenue.