December 9th 2024.
After an investigation by ProPublica revealed that major insurance companies, such as CVS and UnitedHealthcare Group, were utilizing the services of EviCore by Evernorth, a subsidiary of Cigna, to deny coverage to policyholders using an artificial intelligence algorithm, a Senate subcommittee has taken action to hold UnitedHealthcare Group accountable for their actions. The news sparked outrage and concern as people shared their personal experiences of being denied coverage by the company.
The recent shooting of UnitedHealthcare Group's CEO, Brian Thompson, has brought even more attention to the company and its practices. According to the Minneapolis Star-Tribune, this has prompted an increase in individuals sharing their stories online about being denied coverage by the for-profit insurance company. However, this is not the first time the company has faced scrutiny. In October, a Senate report criticized three of the largest Medicare Advantage insurance companies, including CVS, Humana, and UnitedHealthcare, for their high rate of denials.
The report revealed that between 2019 and 2022, the three companies had denied prior authorization requests at an alarming rate. UnitedHealthcare and CVS had a denial rate three times higher than their overall denial rate, while Humana's denial rate was over 16 times higher. This increase in denials was found to be directly linked to higher profits for the companies, according to Senator Richard Blumenthal, chair of the U.S. Senate Permanent Subcommittee on Investigations.
Blumenthal stated, "Insurance companies claim that prior authorization is necessary to prevent unnecessary medical services. However, our subcommittee has obtained new data and internal documents from the largest Medicare Advantage insurers that prove otherwise. In reality, these companies are denying care to vulnerable seniors in order to boost their profits. It's concerning that this practice has only continued to grow in recent years, despite previous criticism and backlash."
ProPublica's investigation also revealed how profit is the main driving force behind insurance companies and EviCore's actions. Although Senator Blumenthal did not directly mention EviCore, the company promises a 3:1 return on investment for insurance companies. This is translated by their salespeople as a 15% increase in denials. Former employees of EviCore have also come forward, claiming that the company's algorithm, known as "the dial," can be manipulated to achieve a desired outcome.
This revelation has caused concern for many, including Dave Jones, a former California insurance commissioner. He stated, "While it may not be a violation of standards to adjust approval or denial rates, it does raise red flags. It suggests that the decision-making process is not entirely objective, which is concerning. It calls into question the integrity of the entire system."
Martin Lustick, a former insurance executive, also expressed his concerns, saying, "The fact that these large companies prioritize profits and have the ability to manipulate the system is deeply troubling. They are playing games with people's health and well-being. It's clear that the more reviews they conduct, the more denials they issue."
Will Humble, executive director for the Arizona Public Health Association, believes that Congress needs to take action in regulating the greed of insurance companies. He specifically points to the Medical Loss Ratio loophole, which incentivizes insurance companies to increase costs for policyholders. In a 2023 op-ed for Arizona Mirror, Humble wrote, "If insurance companies are not held accountable for their greed, it will only lead to worse outcomes for our healthcare system. Across the country, patients are struggling to afford necessary care, while hospitals struggle to keep their doors open. Meanwhile, insurance companies are raking in billions of dollars. We need stricter regulations in place to ensure that these companies prioritize the well-being of their customers over profits."
Humble continued, "It's clear that Congress needs to step in and address this issue in order to lower the cost of healthcare and prevent further abuses by the insurance industry. We cannot rely on these companies to put the needs of their customers first. It's up to our government to intervene and protect the interests of the people."
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