Mansell, Engel & Cole

What is driving policyholder complaints against one large insurer?

“Unfortunately, far too many patients today receive care that’s not evidence-based.”

So says a principal with a company that runs interference for national health insurer Blue Cross Blue Shield. Dr. Eric Gratias and his company eviCore are recipients of outsourced work sent their way by BCBS. The entity plays a central role as a for-profit company in ruling upon care providers’ prior-authorization requests made on behalf of patients. Blue Cross authorization approvals and denials are based on eviCore’s recommendations.

Increasingly, patients and medical groups are having a problem with that, given eviCore’s obvious business rationale stressing profits over expenses. One statewide hospital association recently challenged the BCBS/eviCore relationship, calling for a government investigation into prior authorizations.

The association’s president accompanied that probe request with sharp words He told state officials that BCBS’s use of eviCore as a gatekeeper of patient care “appears to be intentionally designed to delay care for patients … and enable BCBS to deny payment for as many covered services as possible.”

The insurer vehemently denies that. And Gratias stresses that, notwithstanding frequent eviCore denials of recommended services, his company is more friend than foe to patients, ensuring that their care “meets the latest evidence-based guidelines.”

That claim strikes many critics as outlandish and even in bad faith. It is unquestionable that legions of health care principals believe that doctors who actually see and diagnose patient conditions are better arbiters of what comprises proper treatment than are for-profit employees working in a distant company.

The investigation into BCBS’s prior-authorization scheme is ongoing, with regulators saying that it could potentially expand

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