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Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Treatments
When companies like Aetna or UnitedHealthcare want to rein in costs, they turn to EviCore, whose business model depends on turning down payments for care recommended by doctors for their patients.
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. The statement noted that doctors have the ability to appeal prior authorization denials, and that the company routinely monitors the outcomes “as part of our continuous quality improvement to ensure accurate and timely medical necessity decision-making.” To decrease such spending, insurers began requiring doctors to seek permission for medical care before agreeing to pay for it — a process known as “utilization review.” As treatments became more complex, the reviews proved costly in themselves.
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