Skilled nursing facilities already face aggressive prior authorization denials from Medicare Advantage plans, and this investigation shows those decisions are often made by third-party vendors incentivized to deny care rather than approve it.
Every day, patients across America crack open envelopes with bad news. Yet another health insurer has decided not to pay for a treatment that their doctor has recommended. Sometimes it’s a no for an MRI for a high school wrestler with a strained back. Sometimes for a cancer procedure that will help a grandmother with a throat tumor. Sometimes for a heart scan for a truck driver feeling short of breath.
But the insurance companies don’t always make these decisions. Instead, they often outsource medical reviews to a largely hidden industry that makes money by turning down doctors’ requests for payments, known as prior authorizations. Call it the denials for dollars business.
ProPublica, October 23, 2024
Miller, T. Christian, et al. ““Not Medically Necessary”: Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care.” ProPublica, 23 Oct. 2024. https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations.
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