EviCore, owned by Cigna, uses a tunable AI algorithm to drive prior authorization denials for 100 million Americans on behalf of Aetna, UnitedHealthcare, and others.
Key Takeaways
EviCore’s “dial” algorithm scores requests and routes borderline cases to human reviewers; adjusting the threshold directly controls denial volume.
Some EviCore contracts are risk-based: it pockets savings when spending on procedures like MRIs falls below insurer baselines, aligning revenue with denials.
EviCore markets a 3-to-1 ROI to insurers and has internally boasted of achieving 15% increases in denials.
Arkansas mandates denial rate disclosure; EviCore’s rate hit ~20% vs. ~7% for Medicare Advantage in 2022.
Medical guidelines are also used as a cost lever: executives directed closer scrutiny of guidelines when savings targets were missed, per former employees.
Hacker News Comment Review
Physicians report that “peer-to-peer” denial reviews rarely involve actual physician peers as a first line, undermining the regulatory framing that only doctors can issue final denials.
Commenters drew a sharp distinction between traditional Medicare with a Medigap Plan G/F and Medicare Advantage, framing the latter as a private HMO with all the same prior-auth problems.
The US spends more public tax dollars on healthcare than any other country total, then layers private spending on top, yet achieves middling outcomes – context that sharpens the EviCore ROI pitch as a systemic problem, not an edge case.
Notable Comments
@ro_bit: Carelon (then AIM) allegedly set fax machines to accept only 5-10 pages as a denial tactic, settled for $13M in 2022.
@jmux: Connecticut fined EviCore $16,000 for 77+ violations across 196 files – “fines should be a % of yearly profit.”
@wingspar: Suggests escalating denials by demanding the insurer’s HIPAA Compliance/Privacy Officer rather than standard appeals channels.
