«The system also runs in reverse. When doctors or employer health plans complain about high rejection rates, insurance companies can ask EviCore to back off. The company simply adjusts its algorithm to approve more prior authorization requests.
Dave Jones, a former California insurance commissioner and now director of the climate risk initiative at the University of California, Berkeley School of Law, said arbitrarily increasing or decreasing manual reviews didn’t appear to violate any standards. Still, he questioned whether a payment structure or contract for EviCore based on reducing claims payments or authorizations would result in objective and thorough evaluations of prior authorization requests, as required by law.
“That to me is troubling,” Jones said. “It suggests that the claim settlement procedure is not objective, right?” He added, “It calls into question everything that’s occurring.”»
(a) Physicians need to speak up more loudly about inappropriate denials, and (b) yeah, that’s troubling. One hopes the right requests are being approved and denied, but it sounds like a crap shoot, really.
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