"Not Medically Necessary": Helping America's Health Insurers Deny Coverage
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Cigna 公司旗下的 EviCore by Evernorth 是这一相对隐蔽行业中的最大参与者，为超过 1 亿美国人的医疗承保决策提供外包服务，约占三分之一的参保人群。调查发现，该公司使用一种内部称为"拨盘"的人工智能算法来调整索赔被拒的概率，且一些合同通过经济激励鼓励提高拒绝率以减少医疗支出。根据内部文件和对多名前雇员及行业专家的访谈，EviCore 向保险公司承诺投资回报率为 3 比 1——即保险公司每付给该公司 1 美元，就能在医疗费用上节省 3 美元。
调查显示，EviCore 利用该算法来批准或拒绝预先授权请求，算法会根据批准的概率给请求打分。前雇员表示，公司可以调整将案件交由人工复核的门槛，从而随意提高或降低拒绝率。更多的复核往往导致更多的拒绝，因为只有医生在参考公司医疗指南后才能做出最终拒绝。这些指南多次受到医疗团体的批评，包括美国心脏病学会和美国放射肿瘤学会，批评点包括过时、僵化，导致不当拒绝或延误必要治疗，因此一些医生戏称该公司为"EvilCore"。
来自俄亥俄州的 61 岁焊工 Little John Cupp 的案例反映了这种做法的人为后果。当他出现心脏症状时，医生要求进行心脏导管检查，但 EviCore 两次以"不具医疗必要性"为由拒绝。医院改为为他做了费用更低的核成像运动负荷试验，结果显示心功能恶化。他在接受该检查后仅 36 小时便因心脏骤停去世。虽然部分医学专家对是否需要导管检查存在分歧，但也有人认为该手术可能挽救了他的生命，并称最初的拒绝是不负责任的。 Cupp 的女儿 Chris 曾对多方提起诉讼，但因针对雇主提供的健康计划的诉讼必须在联邦法院审理，而相关判例通常偏向保险公司，她不得不放弃对 UnitedHealthcare 和 EviCore 的追责。
调查还发现，EviCore 不仅通过直接拒绝来节约成本，还通过高管所称的"哨兵效应"实现节省：一旦医生知道有公司在监控，他们就可能干脆不再提出某些检查或治疗的申请。以佛蒙特州为例，心脏科的预先授权请求在一年多的时间里下降了 38% 。尽管 EviCore 及其母公司 Cigna 声称公司依循循证医学以提升质量和安全、减少不必要的支出，但像美国医学会前主席 Barbara McAneny 这样的医疗专业人士认为，这一体系把利润置于病人护理之上。 EviCore 也并非个例，竞争对手如 Elevance Health 旗下的 Carelon Medical Benefits Management 也有类似做法，并涉及已和解的"不当拒绝"诉讼。
监管机构很少对像 EviCore 这样的公司处以重大惩罚。康涅狄格州保险部门在审查 196 份档案后发现 77 项违规，仅对 EviCore 处以 1.6 万美元的罚款。该公司还获得了一些行业协会的认证，这些协会审查其是否符合行业标准。 Chris Cupp 现在靠开校车维持生计，她对保险公司在生死攸关的治疗决策中拥有过多话语权感到愤怒，尤其是对像心脏病这样可能致命的疾病。她希望通过讲述自己的遭遇，能阻止其他人因保险拒绝而遭遇同样可被预防的死亡。
EviCore by Evernorth, owned by Cigna, is the largest player in a largely hidden industry that outsources medical coverage decisions for more than 100 million Americans, about 1 in 3 insured people. A ProPublica and Capitol Forum investigation found the company uses an artificial intelligence algorithm known internally as "the dial" to adjust the likelihood of claim denials, with some contracts financially incentivizing higher denial rates to reduce health spending. The investigation, based on internal documents and dozens of interviews with former employees and industry experts, revealed that EviCore promises insurers a 3-to-1 return on investment, meaning for every dollar spent on the company, insurers pay three dollars less on medical care and costs.
The investigation showed that EviCore approves or denies prior authorization requests using this algorithm, which scores requests based on the probability of approval. Former employees explained that the company can adjust the threshold for sending cases for human review, thereby increasing or decreasing denial rates at will. More reviews lead to more denials since only doctors can issue final denials after consulting company medical guidelines. These guidelines have been repeatedly criticized by medical groups, including the American College of Cardiology and the American Society for Radiation Oncology, as being outdated, rigid, and resulting in inappropriate denials or delays in necessary care, leading some doctors to refer to the company as "EvilCore."
The story of Little John Cupp, a 61-year-old welder from Ohio, illustrates the human impact. After developing cardiac symptoms, his doctor requested a heart catheterization, but EviCore denied it twice as "not medically necessary." Cupp was instead given a less expensive nuclear stress test, which revealed worsening heart function. He died of cardiac arrest just 36 hours after that test. While some medical experts disagreed on whether the catheterization was necessary, others argued it could have saved his life, with one calling the original denial irresponsible. Cupp's daughter, Chris, sued multiple parties but was forced to drop UnitedHealthcare and EviCore because lawsuits against employer-filed health plans must be tried in federal court where case law favors insurers.
The investigation found that EviCore achieved cost savings not only through denials but also through what executives call the "sentinel effect," where doctors stop requesting procedures altogether once they know the company is watching. In Vermont, cardiology prior authorization requests dropped 38% in a little over a year. While EviCore and its parent company Cigna stated that the company uses evidence-based medicine to improve quality and safety while reducing unnecessary costs, medical professionals like former AMA president Barbara McAneny argued the system prioritizes profit over patient care. The company is not alone, as competitors like Carelon Medical Benefits Management, a subsidiary of Elevance Health, also engage in similar practices, including settled lawsuits alleging improper denials.
Regulators rarely impose significant penalties on companies like EviCore. Connecticut's insurance department recently fined EviCore just $16,000 for over 77 violations found in a review of 196 files. The company is also accredited by trade associations that review compliance with industry standards. Chris Cupp, who now drives a school bus to make ends meet, expressed frustration that insurers have too much say over life-saving decisions, especially regarding conditions like heart disease that can be fatal. She hopes sharing her story will prevent others from experiencing similar preventable deaths due to insurance denials.
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• 保险拒赔流程通常由非临床人员或与相关专科无关的医生进行所谓的"同行评审"决定，形成一个有意让医疗提供者和患者疲于应对、放弃争取必要治疗的体系。
• 挑战拒赔的一种做法是要求保险方提供所有查看您病历并参与拒赔决定人员的姓名和资质信息，因为保险公司通常不愿让人知道，很多拒赔其实由资质不足的审核者而非受委员会认证的专科医生作出。
• 拒赔体系充当一种有意的筛选机制。许多医疗机构不加质疑地接受拒赔结果，许多患者也缺乏抗争资源；即便有人提出上诉，最终多数也会放弃。被撤销的拒赔仅占极小比例，这实际上是一种精心计算的成本节约策略。
• "非医疗必需"本应是基于医学专业判断，由具备相应资质和执业许可的医生来决定，但保险公司却常把它当作商业决策，从而在法律上淡化责任归属。
• 医疗提供者为应对保险拒赔投入大量无偿时间，这些隐性成本最终被转嫁到门诊和手术费用上，推动了医疗行政支出的上升。
• 传统的 Medicare 提供更明确的覆盖指南、较少的事先授权流程；虽然 Medicare Advantage 初始保费较低、吸引了许多参保者，但随后他们往往面临更多持续的覆盖争议。
• 对违反覆盖规定的保险公司处以的罚款（例如 EviCore 因 77 项违规被罚 16,000 美元）与公司利润相比微不足道，难以对有害行为形成实质威慑。
• 美国的人均医疗支出及占国民总支出的医疗开销均高居全球前列，但健康结果仅属中等，表明问题在于系统性效率低下而非资金短缺。
• 诸如 UnitedHealthcare 的保险公司通过收购医生诊所实现垂直整合，并向自有诊所支付高于独立诊所的费用，从而在医疗支出中攫取更大份额，同时将保费上涨归咎于医疗服务提供者的成本。
• 关于保险官僚体制的最终成本由谁承担、医疗支出的主要驱动因素是医生收入还是保险公司利润，存在诸多争议，人们对国家医疗支出数据有不同解读。
• 获取及时医疗服务的困难导致即便有良好保险的患者也要面对漫长等待、反复计费错误以及为常规服务而进行的疲惫行政争斗。
讨论显示，人们普遍对美国保险做法不满。参与者指出系统性问题：保险公司借助官僚障碍与资质不足的审核人员来拒赔，并且精算出多数申诉最终会被放弃。关于应由医疗提供者还是保险公司为高昂成本承担主要责任存在分歧，但各方一致认为当前体系将大量资源浪费在行政管理上，而非用于医疗服务。有评论者指出，即使有良好保险的美国人也难以及时获得医疗，整个系统似乎在牺牲患者疗效的同时最大化保险公司利润。 • Insurance denial processes often involve non-physicians or doctors from unrelated specialties making "peer-to-peer" decisions, creating a system designed to wear down providers and patients until they give up fighting for necessary care.
• A strategy for challenging denials involves requesting the names and credentials of everyone who accessed your medical record to make the denial decision, as insurance companies typically don't want you to know that denials are often made by underqualified personnel rather than board-certified specialists.
• The denial system functions as a deliberate filter. Many providers accept denials without challenge, many patients lack the resources to fight, and even among those who do contest, most eventually give up. The small percentage of reversals represents a calculated cost-saving strategy.
• "Not medically necessary" is a medical determination that should require appropriate medical credentials and licensing, yet insurance companies use this phrase while claiming it's merely a business decision, creating legal ambiguity about liability.
• Healthcare providers spend substantial unpaid time fighting insurance denials, a cost that gets folded into billing rates for appointments and procedures, contributing to rising administrative healthcare costs.
• Traditional Medicare offers clearer coverage guidelines and less preauthorization bureaucracy than Medicare Advantage plans, though Medicare Advantage's lower initial costs tempt many enrollees who then face ongoing coverage disputes.
• Fines for insurance companies violating coverage requirements, such as EviCore's $16,000 fine for 77 violations, are trivial relative to company profits and fail to deter harmful practices.
• The US spends more per capita and in total tax dollars on healthcare than any other country while achieving middling outcomes, suggesting systemic inefficiency rather than underfunding.
• Insurance companies like UnitedHealthcare are vertically integrating by purchasing physician practices and paying their own practices more than independent ones, increasing their share of healthcare spending while blaming provider costs for premium increases.
• There are questions about who ultimately bears the costs of insurance bureaucracy and whether practitioner income or insurer profits are the primary drivers of healthcare spending, with different interpretations of national health expenditure data.
• The difficulty of accessing timely care creates situations where patients face long wait times, repeated billing errors, and exhausting administrative battles for routine services, even among those with good insurance.
The discussion reveals widespread frustration with US healthcare insurance practices. Participants highlight systemic issues where insurance companies use bureaucratic obstacles and underqualified reviewers to deny care, calculating that most challenges will be abandoned. There's disagreement about whether providers or insurers bear more responsibility for high costs, but consensus that the current system wastes significant resources on administration rather than care. Several commenters note that even well-insured Americans face substantial barriers to timely medical services, with the system appearing designed to maximize insurer profits at the expense of patient outcomes.