EviCore, owned by Cigna, uses a tunable AI algorithm to drive prior authorization denials for 100 million insured Americans on behalf of Aetna, UnitedHealthcare, and others.
Key Takeaways
EviCore’s “dial” algorithm scores prior auth requests; lowering the auto-approve threshold pushes more cases to human review, directly increasing denial rates.
Some contracts are “risk contracts” where EviCore pockets savings when it keeps procedure costs below a baseline, aligning profit directly with denials.
EviCore markets a 3-to-1 ROI to insurers and internally tracked a 15% increase in denials as a sales metric.
Arkansas-mandated disclosure shows EviCore denied ~20% of requests since 2021, versus ~7% for Medicare Advantage plans in 2022.
Medical guidelines are also adjusted by client to hit savings targets, with executives directing closer scrutiny when a client “isn’t showing savings.”
Hacker News Comment Review
Physicians report that “peer-to-peer” denial reviews often involve non-physicians as a first line, undermining the stated requirement that only doctors issue final denials.
No substantive disagreement or technical counterpoints in current discussion; commentary is early and thin.
Notable Comments
@vanc_cefepime: practicing physician says peer-to-peer review contacts are frequently non-physicians, contradicting EviCore’s claim that only doctors issue denials.
