What happened

EviCore employs an AI algorithm nicknamed "the dial" to evaluate so-called "prior authorisation requests", leading to denial rates for medical procedures as high as 20 percent in some US states -significantly higher than the 7 percent average for Medicare Advantage plans - according to a  ProPublica investigation. 

For example, John Cupp was denied a heart catheterisation twice and subsequently died of cardiac arrest. A 2018 audit by the Centers for Medicare and Medicaid Services found that EviCore played a role in making "inappropriate denials" for 30 cancer patients due to outdated guidelines.

Why it happened

EviCore's business model promises insurers a 3-to-1 return on investment, incentivising the company to increase denial rates. 

Its algorithm can be adjusted to send more requests for manual review, increasing the likelihood of denials. 

Additionally, some contracts allow EviCore to earn more money by cutting health spending, further motivating the company to deny claims.