EviCore Turns Up the Dial on Denials: When Profits Drive Healthcare Decisions

A groundbreaking October 2024 ProPublica and Capitol Forum investigation has uncovered disturbing practices in healthcare management, revealing how artificial intelligence is being weaponized to restrict patient care. At the center of this investigation is EviCore by Evernorth, a company owned by insurance giant Cigna that manages healthcare decisions for approximately 100 million Americans (about 1 in 3 insured people) using what insiders call "the dial," - a proprietary algorithm that can systematically increase denial rates.

What is EviCore?

EviCore is a benefits management company that major American insurance companies hire to make prior authorization decisions—the approval process required before patients can receive certain treatments. Rather than insurers making these decisions themselves, they outsource them to EviCore, which then determines whether to approve doctors' requests for payment for surgeries, MRIs, or other treatments.

Understanding "The Dial"

The investigation reveals that EviCore's algorithm is far more than a simple efficiency tool. Former employees have exposed how this system operates:

The algorithm calculates a probability score for each treatment request's approval. Management can adjust thresholds at will, forcing more cases into manual review processes. These reviews consistently lead to higher denial rates, with sales teams proudly advertising 15% increases in denials to potential clients.

The Human Toll

The consequences of these algorithmic decisions are devastating. One particularly tragic case involved Little John Cupp, a 61-year-old welder whose doctor recommended an urgent heart catheterization. EviCore denied this procedure in favor of a less expensive alternative. Within 36 hours, the patient suffered a fatal cardiac arrest, leaving behind a grieving family - a stark illustration of how profit-driven healthcare decisions can have fatal consequences.

The Business of Denial

The numbers paint a troubling picture of healthcare prioritizing profits over patients:

EviCore markets itself to insurers with the promise of a 3-to-1 return on investment. In Arkansas, nearly 20% of requests face denial - almost triple the 7% rate seen in Medicare Advantage programs. Doctors are forced to process 15 cases per hour, allowing just four minutes per patient case. Perhaps most disturbing is the celebration of what they call the "sentinel effect" - when doctors simply stop requesting care they believe their patients need.

This practice extends beyond EviCore. Companies like Carelon Medical Benefits Management have built similar business models around healthcare denials, creating an industry that measures success by how effectively it discourages doctors from advocating for their patients' care.

The fundamental question remains: In a healthcare system where success is measured by how many doctors stop fighting for optimal patient care, what happens to the core mission of medicine? This investigation serves as a crucial warning about the growing influence of profit-driven algorithms in healthcare decision-making and the urgent need for reform to protect patient interests.

The findings highlight a critical juncture in American healthcare, where we must decide whether to allow artificial intelligence and profit motives to override medical expertise and patient needs. As regulatory reforms take effect in 2026 and states continue passing protective legislation, the urgent need for oversight and accountability has never been clearer. The story of Little John Cupp and countless others serves as a stark reminder that behind every denied claim is a real person whose health—and life—hangs in the balance.