Inside Look: The Companies Helping Insurance Companies Deny Pre-Authorization Claims

There's a hidden industry is making money by turning down doctors’ requests for payments, known as prior authorizations.

A KFF survey found that roughly 6 in 10 insured adults have experienced problems when using their insurance. The issues range from denied claims to network adequacy, preauthorization delays, and denials. According to a ProPublica investigation, this comes as no surprise. A hidden industry makes money by rejecting doctors’ payment requests, known as prior authorizations.

According to ProPublica’s investigation, one key player in this scheme is a company called EviCore by Evernorth. ProPublica’s investigation found that EviCore is owned by a major insurance company, Cigna. Major American insurance companies hire EviCore and provide coverage to 100 million consumers.

EviCore reportedly uses an algorithm backed by artificial intelligence that insurance insiders call “the dial.” The algorithm system can be adjusted, ultimately leading to higher denials of preauthorization claims.

Even more bizarre is that EviCore reportedly has some contracts that allow it to get paid more the more it cuts back on health spending for insurance companies.

EviCore is not alone. Another big player is Carelon Medical Benefits Management, an Elevance Health subsidiary formerly Anthem. While the company is being accused in court of wrongfully denying legitimate requests for coverage, it denies all charges.

How The Companies Are Responding

EviCore claims that the approval process ensures that procedures are safe, necessary, and cost-effective.

“We are improving the quality of health care, the safety of health care and, by very happy coincidence, we’re also decreasing a significant amount of unnecessary costs,” an EviCore medical officer said during the company’s webinar series.

Yet, according to the investigation, EviCore’s approach is far more sinister than it’s leading on. EviCore reportedly promises a 3-to-1 return on investment, meaning the insurer would pay $3 less on medical care and other costs.

For some perspective, EviCore turned down prior authorization requests nearly 20% of the time in Arkansas in 2021. According to ProPublica’s data analysis, Medicare Advantage plans turned down prior authorization requests about 7% of the time in 2022.

A Cigna spokesperson said on behalf of EviCore, “Simply put, EviCore uses the latest evidence-based medicine to ensure that patients receive the care they need and avoid the services they do not.”

The spokesperson added that the company uses algorithms for some clinical programs “only to accelerate approval of appropriate care and reduce the administrative burden on providers.”