The Company Helping America's Health Insurers Deny Coverage for Care (opens in new tab)

Evicore is a highly suspicious company, and the story of the patient who passed away in this article is sad. But I have noticed insurers do this (false claim denials) all on their own too. I and many friends have experienced Aetna routinely denying things that are explicitly covered by their plans and mentioned in the plan documents. They force you into an exhaustive cat and mouse game of chasing their team to reprocess denied claims. But after the initial denial, every conversation goes to some other part of their support team with hour long waiting times (meaning you may have to try multiple times across multiple weeks due to other obligations in your schedule), incompetent staff that barely speak English (making it hard to get the info or action you want), and very loose commitments from Aetna (they’ll promise getting back in 45 business days but even with that they won’t have done anything when you check in weeks later). I think these are purposeful games meant to deter people from successfully filing claims, by exhausting them, or simply shifting their payments into the future. I feel it is criminal. Not just in terms of fraudulent denial but in affecting people’s health by creating stress for them over big medical bills that should be covered.

I frequently have to deal with this, particularly peer-to-peer (P2P) authorization. I have never been assigned a practising oncologist as a peer. Often a retired unrelated speciality (paediatrician, psychiatrist) or a non-practising insurance doctor. They are unfamiliar with any of the data in the field, and they read off cards provided to them by their "third party" employer to deny care, even care that falls within national guidelines. I had to escalate this to the CMO of the insurance company before, at which time they admitted that the treatment should have been approved from the beginning. Their goal is to make the process frustrating ("just call this number..." it's a phone tree), introduce delays ("please fax your appeal to this garbage can and we will consider looking at it between 72 hours and never"), require multiple layered appeals ("so I'm just the peer to a peer reviewer, and my guidelines say to deny this, but you are welcome to appeal to a panel that might read the references you already sent in"), and anything else to ensure that patients stop pursuing care and die before getting expensive drugs.

It is never based on quality care, but on increasing friction and pain in the system in order to minimize payments out of money already collected from patients. It is a criminal racket and nothing makes me angrier in my entire practice.

It's as if you need insurance for the insurance.

Does anyone know if this service exists? E.g. if they deny, you don't even talk to them, you forward it straight to your insurance insurance and their lawyer instantly threatens to sue them?

Here and in taxes complexity is a problem. Any chem Eng or Drucker/Ishikawa/Deming person will want to simplify.

Second, and as a commentor here reminds, patients are often on the line for money (accountability) when the axis of control (the other side of same coin) is between the hospital and insurer.

Every time accountability is separated from control you've get big problems, and incentives to do the wrong thing.

Variations include providers over billing, billing wrong procedure etc. or denying claims on the other side.

All that stuff is done electronically between the provider and insurer (an axis of control) without the insured ever even knowing. Thus bad providers see the patient's policy like a wallet found on the ground.

Contrast with most commercial transactions: the service provider has no/none/zero access to any customer money directly or indirectly. All the provider can do is bill the customer (with an itemized bill). This way the customer decides if they part with money instead of the provider helping themselves to money.

I could add my own horror stories .. but will not waste your time.

I would love to see in the next 20 years,

- accurate itemized bills from hospitals/providers

- bills submitted to patients and only patients. Provider access to patient's insurance cutoff.

- patients if they agree electronically submit to their insurance giving them incentive to not commit fraud and use their benefits smartly

- providers and insurers who mostly work between each other put the insured in the center of the picture

- which requires providers and insurers to simplify and bring their business practice more in line with everybody else.

Yes, health care billing is more complicated than buying a car or upgrading your bathroom, but I harbor the suspicion that patients can do a lot more and insurance people act like it's impenetrable through self inflicted and self injected complexity.

A few years ago, as my rebellion ramped up, I enrolled in a Christian Health Sharing Ministry. They published extensive disclaimers, telling members, "THIS IS NOT INSURANCE. DO NOT TREAT IT LIKE INSURANCE. WE RECOMMEND THAT YOU CARRY REAL INSURANCE."

Of course, I couldn't afford both the Health Share and real insurance, so I took the risk. But it soon became apparent that I was in over my head.

I barely understood the whole insurance claims/billing process. I had not been too involved, since Medicaid coverage had made a lot of that effortless and invisible.

So I had to learn about all these billing practices, and what's more, the Health Share had their own terminology that was parallel, but not equivalent, to insurance terminology. Thankfully, they published a detailed Lexicon document, in addition to their Sharing Guidelines.

All claims (Medical Needs) were manual. No providers would directly bill the HSM. The bills they sent to me were useless for this purpose. I needed to cajole each provider into generating an itemized "SuperBill" with all the info required for the HSM. Then I'd submit it to the HSM and literally pray.

I put up with this for a couple of years. I heard from other people how draining it was to deal with all this. So I finally withdrew. Now I carry regular Marketplace insurance.

But I'm descending into a hellscape of bureaucracy, and I'm scared of it. For years I've been trying to advocate for my health and reduce my health care costs by refusing unnecessary treatments that were making me sicker, and worsening my conditions.

But the insurance company seems hell bent on sending me on fool's errands and wild goose chases. For example, I didn't receive any billing communication for two months. Then, AutoPay failed last month. They sent me incorrectly-worded warning notices. I went around and around with CSRs about this. Finally we kicked the can down the road. They assured me that my insurance wouldn't terminate as it had been threatened.

But now my PCP's office is coming back to me with denials from 6 months ago. I'm tearing my hair out. Indeed, why do I need to be in the loop? They are filing claims. Their billing department needs to work this out. I'm powerless to tell my [ex-]insurance carrier what to do. I already sent them proof of coverage! Leave me alone!

It's a nightmare, and I predict that it will eventually eat my entire life. Many elderly people are slaves to their physicians and specialists and medications. My own parents are on a constant treadmill of doctor's appointments, every week, blood draws, ridiculously complex medication rituals.

My sanity and faith in Christ is worth far more than cooperation with these mendacious, lying, thieving swine. Mark my words.