OK, in the last few weeks we had a Senate report on Prior Auth, and a CAP report on the bad behavior of payers:
https://www.discoveriesinhealthpolicy.com/2024/10/new-cap-report-intolerable-burdens-of.html
[If you get an insurance denial,] 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....
 |
| Pro Publica, October 23, 2024 Miller et al. |
Since the article includes a section about AI and prior auth, let's see Chat GPT 4o summarize the article in 8 main points:
Here are eight key takeaways from the article, focusing on aspects relevant to the provider and laboratory industry:
EviCore’s Algorithmic "Dial": EviCore, owned by Cigna, uses an AI-based algorithm, known as "the dial," to control approval rates. Adjusting this dial can increase denials, often requiring further review by nurses or physicians, thereby delaying care.
Incentivized Denials: Certain contracts incentivize EviCore to cut healthcare costs, leading to a "denials-for-dollars" model where the company earns more by denying more treatments or reducing authorization requests.
Rigid Guidelines and Delays: EviCore's guidelines are criticized for being outdated and rigid, resulting in denials or delays for necessary care. Medical societies have raised concerns about these guidelines, especially regarding certain treatments like proton beam therapy.
Risk-Based Contracts: EviCore’s lucrative “risk model” contracts let them profit from cost savings if they keep insurance claims below set thresholds, creating a potential conflict of interest in care recommendations.
High-Touch Plans for More Denials: Large insurers like Aetna and Cigna sometimes request “high touch” plans that send more cases to manual review, increasing denial rates and impacting providers’ ability to deliver timely care.
Impact on Provider Behavior: The "sentinel effect" means providers request fewer prior authorizations when working with EviCore, likely due to the complexity and frustration involved, which may result in necessary procedures not being pursued.
Lawsuits and Accountability Challenges: While EviCore faces criticism for these practices, they and similar companies are rarely penalized significantly. Legal barriers make it difficult for patients and providers to hold them accountable.
Mixed Impact on Quality and Cost: Although marketed as improving care by reducing waste, the article suggests EviCore’s cost-cutting primarily benefits insurers financially, with limited demonstrated benefit to patient outcomes. [end chat gpt]
