Medical Care Denied –
When you need medical care, it can be painful or even dangerous to have to wait to receive it.
But, insurance companies are more often requiring prior authorization before agreeing to pay for
the medical treatment prescribed by your doctor. According to the American Medical Association,
almost three- quarters of doctors have seen an increase in pre-authorization denials. This causes
a delay in treatment and may lead to adverse events for some patients.
Prior authorization can help prevent doctors from recommending unnecessary treatments and protect
insurers from fraudulent overbilling. But it can be misused to benefit the bot- tom line of
insurers and the medical review companies that decide which treatments are approved.
When your insurance company turns you down for a doctor-recommended medical test or procedure, the
insurance company may not be the one making the decision.
To save on administrative costs, many health insurers outsource the approval process to medical
review companies. The largest of these is EviCore, owned by Cigna Group, a global insurance
company.
EviCore works with more than 100
insurers nationwide, including: Aetna and
UnitedHealthcare. Its medical review contracts cover over 100 million consumers — about a third of all insured people.
According to a recent investigation
by ProPublica, an independent,
nonprofit news agency, EviCore uses
algorithms and artificial intelligence
to review claims.
The AI review cannot deny your claim directly; it must either authorize the medical treatment or
send
it for further review.
If the health insurer feels it is paying too much, algorithms can be adjusted to send more claims for
review. The result is fewer approvals for treatment and more money for the insurer’s bottom line.
The final decision on approval of treatment is made by a company doctor using internal treatment guidelines developed by the medical review
company. Review companies claim the guidelines are based on the latest evidence-backed practices.
But medical organizations such as the American College of Cardiology and the Society of Vascular Surgery claim the guidelines are outdated,
flawed and can interfere with appropriate
patient care.
Insurers also claim they are working to protect patients from rising costs of health care. But health-care providers argue that delay and denial of
coverage interferes with patient care and, in some cases, causes harm.
Few patients appeal a denial of
coverage. The appeals procedure can
be complex and the medical terminology
unfamiliar to the average person.
Some states passed laws to limit
pre-authorization reviews, shorten
delays and increase public reporting
on the process.
