“Not Medically Necessary”: Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care
"America’s largest insurers hire EviCore to make decisions on whether to pay for care for more than 100 million people. “The Dial”: EviCore uses an algorithm that allows it to adjust the chances that company doctors will screen prior authorization requests, increasing the possibility of denials.
Lucrative Deals: Some EviCore contracts are based on how deeply the company can reduce spending on medical procedures. It tells insurers that it can provide a 3-to-1 return on investment.
"Over the years, medical groups have repeatedly complained that EviCore’s guidelines were outdated and rigid, resulting in inappropriate denials or delays in care."
"Known as risk contracts, EviCore takes on the responsibility for paying claims. As an example, say an insurer spends $10 million a year on MRIs. If EviCore keeps costs below that figure, it pockets the difference. In some cases, it splits the savings with the insurance company. “Where you really made your money was on a risk model,” a former EviCore executive said. “Their margins were exponentially higher. Insurers do not make explicit demands for more denials, a former EviCore sales executive said, Instead, they asked about “controlling the spend” — the amount of money paid out on certain procedures, he said. Nor would EviCore always use the word “denials” — they employed circumlocutions like “inappropriate determinations.”
"A 2023 academic study examined the criteria EviCore used to approve payment for imaging of the lower spine in cases of extreme pain. It found the guidelines deficient. Two of five medical experts who reviewed the guidelines even recommended not using them. ( A critical appraisal of Evicore’s guidelines for advanced diagnostic imaging of the spine for lower extremity pain with neurological features ) "Nine months after starting at EviCore, Miller quit, disappointed by the attitudes of some of her colleagues. “Most of the physicians who work at these places just don’t care,” she said. “Any empathy they had is gone.”
Another way that EviCore reduces costs for insurers is that doctors make fewer reque4sts for procedures. EviCore says this is because doctors make fewer inappropriate requests, doctors say they give up because fighting to get procedures for their patients is too time-consuming. Cigna, who owns EviCore, claims that this effect (called the "sentinel effect") occurs because doctors are kept more up-to-date on current procedures. "Connecticut’s Insurance Department recently reviewed EviCore and Carelon. It found no problems with Carelon. EviCore was fined $16,000 this year for more than 77 violations found in a review of 196 files."
"In 2022, Carelon settled a lawsuit for $13 million that alleged the company, then called AIM, had used a variety of techniques to avoid approving coverage requests. Among them: The company set its fax machines to receive only 5 to 10 pages. When doctors faxed prior authorization requests longer than the limit, company representatives would deny them for failing to have enough documentation. Carelon denied the allegations in court and admitted no fault."
"Lawsuits against employer-funded health plans, like the one Cupp had with United, must be tried in federal court, where case law favors insurance companies. For instance, insurers found at fault do not pay punitive damages, only the cost of treatment."
AMA survey finds prior authorization hurts patients and doctors
"Health systems should also expect higher drug costs. Hospital drug expenses are 12% higher than in 2020. Hospitals also need to get accustomed to patients shifting more toward outpatient facilities, Swanson said." from https://www.chiefhealthcareexecutive.com/view/hospitals-faring-better-than-last-year-but-a-difficult-path-lies-ahead
Eat What You Kill
This report is about an oncologist named Dr. Thomas C. Weiner who practiced in Helena, MT and essentially built a kingdom there for himself at St Peter hospital. He was eventually terminated for all kinds of fraud and harm to patients, including extremely excessive prescribing of opiate medications and the seemingly intentional killing of at least 10 patients but probably many, many more- all under the pretense of "providing comfort". This man comes across as a psychopathic narcissist, essentially a cult leader who used all manner of coercive control and lying to maintain his powerful and extremely lucrative position in the community.
This phrase refers to a reimbursal scheme at some hospitals in which providers are paid for the value of the services they provide. "Adding to a six-figure base salary, his pay was calculated by the number of relative value units, or RVUs, he billed on behalf of the hospital. The system compensates doctors using weighted values for certain types of visits or treatment. It works like this: A doctor might be paid $100 per RVU. A routine physical might be equal to 1 RVU, or $100; a more complicated and time-consuming procedure like radiation therapy might equal 8 RVUs, or $800. In other words, the more patient visits and treatments a doctor bills to insurance, the more that doctor and the hospital earn. Weiner described this system, which is common in American medicine, as “eat what you kill.”
“Comfort” was a word Weiner used often in our conversations. If a patient dies as a result of his treatment, he told me, it’s not unethical if his intent was to provide comfort. In medicine, this is called the principle of double effect. First developed by the Catholic saint and theologian Thomas Aquinas, it’s a set of criteria by which a person can morally justify ending someone’s life. It stipulates that a harmful consequence of a medical treatment, such as death, is permissible if it’s a secondary effect of beneficial treatment, such as alleviating pain with drugs. “It’s for their comfort,” Weiner told me. “It’s not that I euthanize them.”
Can the new CVS CEO handle the Aetna challenge?
This is an article about the replacement of one CVS Health CEO with another because stock value and profitability are the top priorities in how the health care company is run. The stock price had fallen, due in part to their insurance arm Aetna "Health insurance companies typically aim to pay out about 80% of the premiums they collect for customer medical services. CVS said on Friday that the percentage of premiums spent on medical services had risen to 95%."
CVS Health slashes infusion services offerings, blaming industry headwinds
"More than 3.2 million Americans receive some type of infusion therapy each year, according to Bourne’s research. The figure is expected to grow over the upcoming years, as the population over 65 years old is projected to double in the next three decades, chronic disease continues to rise and the Food and Drug Administration green-lights new injection-based drugs."
"Nationwide nursing labor shortages have hit the infusion industry hard because infusion therapy can require a 1-to-1 nurse-to-patient ratio and must be performed by nurses with specialized training, according to Bourne Partners.
Training requirements can push compensation for infusion nurses up 10% to 20% higher than nonspecialized nurses, the consultancy said, straining provider budgets.
In 2022, CVS Health closed 36 of its 71 Coram clinics and laid off 2,000 employees including dietitians, nurses and pharmacists. A KFF News report attributed the closure to high overhead costs associated with providing infusion services, labor costs, reimbursement delays and supply shortages."
The Growth of Private Equity in US Health Care: Impact and Outlook
