From UFOs to psychic powers and government conspiracies. History is riddled with unexplained events. You can turn back now or learn this stuff they don't want you to know. A production of iHeartRadio.
Hello, welcome back to the show. My name is Matt, my name is Noel.
They call me Ben. We're joined as always with our super producer Dylan the Tennessee pal Fagan. Most importantly, you are you. You are here. That makes this the stuff they don't want you to know. Hurtling headlong through April. We wish you the best with your paperwork. I feel like everybody has to deal with paperwork at this point, no matter who you are.
Guys, would you believe I've already done my taxes? I did them, like right away, the moment I got my W two, I feel like such an adult.
Yeah, you were telling me that that's.
Awesome, you know. I mean, it's not bragging, it's just for me. It's a big deal.
Did you get to write off any medical expenses?
No, I didn't. I wrote off a lot of modular synthesizer equipment. Though don't tell Uncle Sam. Now I do use that for business, but yeah, how does that even work? Guys? Like, I don't think I even knew that you could do that.
Yeah, cand you just have to out receipt the other people. It's a war of paperwork attrition, getting your documentation right in the right place, always having the thing when it's asked for in the format it is requested. This leads us to a fascinating conversation we had back in October twenty twenty four with our conspiracy realist K Dog. K Dog, you said something that stood out to all of us, and K Dog and I had a bit of a
correspondence over this. The US healthcare system is diplomatically put complicated. Supporters are going to say it's imperfect, but you know, it's better than nothing, and critics, by which we mean the majority of the US population, will say it's worse than not great. It can be predatory at times. It is not near the level of other developed countries, like right now, as we report, millions of people are attempting to get possibly life saving medications, procedures and surgery.
Yeah, the rest of the world says, why can't you provide that? Don't you guys make a lot of money?
Why is it a crapshoot that you might get like acceptable healthcare. It just seems kind of like a lot of people in the rest of the world look at that as a human.
Right, yeah, because it is. So we're coming in here with a bit of a bias. But this is the quick skinny folks. Here in the United States, patients and doctors can't immediately agree that a procedure life saving right outside of maybe an emergency room. Doctors have to get prior approval from private health insurers to cover part of a medical.
Cost because they're the ones paying for it, right.
Sure, and who, by the way, are not themselves medical professionals, and who are making assessments based on dollars and cents, not necessarily you know, the well being of the patient.
We're going to talk about that because that's why one of the value adds of one of the corporations we're going to be talking about is we use doctors, and we have doctors because doctors have to make those decisions.
Oh right.
This leads us to the story k Dog that you suggested not too long ago, back in October of twenty twenty four. This is the tale of evycore not evil.
Nobody not noticed or like let them know that this is one letter away from being evil core, which sounds like an incredible genre of that high parody.
Account on Twitter.
I think it's evicre e core.
Well, you know what will give them the measure of respect they deserve. Here are the facts. Let's okay for anybody unaware, guys, could we explain what prior approval is. What does it mean.
It's authorization by a medical professional that says, hey, this procedure, this medication, this, whatever it is, is medically necessary for this patient. That's what a prior authorization is. Before the surgery happens, before the MRI test, before the certain exam. Name it that an oncologist would perform, before your heart gets checked out, or you get a catheter in there to make.
Sure you get medication.
Yes, any of that. It's a group of people saying, yes, this is necessary before anybody takes on any further costs.
Yeah. And additionally to this important note, this is evaluated. Part of this is not just whether it's medically necessary, but whether it is specifically covered by whatever hierarchy of plan you have. So even if you definitely need that kidney and you don't have the right plan, you may not get approved, meaning that you would be theoretically responsible for the entirety of that bill.
It's another reason too that it's really really difficult to get certain experimental treatments covered. And you always hear about, you know, people that have cancer and that maybe there's this you know, cutting edge treatment that's being used. That's the kind of stuff or to get the top person, that's the kind of stuff that almost always has to be paid out of pocket and can bankrupt people at the very least cause them to carry massive, massive debt.
I agree. I think one of the things we have to address at the top here is that most medical plans, no matter who's providing them, will state somewhere within the massive documentation you have to sign that medically necessary things will They won't be fully paid for, but depending on your whatever your contract says, they will be paid for with a certain percentage, right.
Sure, after a certain threshold of payments.
Well, yeah, there's like all these different things. Well it just depends. There's all these different things that can go into it. And but ultimately, almost every single one of the healthcare plans that I have seen say within that writing that they will cover medically necessary things, which is why that term, that phrase becomes so important.
Yeah, yeah, and also such a such a foundational stone in the controversy and indeed conspiracy we're discussing here. You know, in theory, the idea of prior approval is used by insurance companies and their health plans and physicians to make sure things are cost effective, that the service is necessary, it's covered. That makes sense. However, we could argue the solution to the second part of covered by your plan could be solved very easily by just getting everyone on
the same plan, like so many other developed countries. Story for another day does need to be mentioned. But in theory, prior approval does mean that drugs and services are going to people who need them.
And which I guess you know, was sort of the point of the Affordable Healthcare Act. But even that in and of itself was like a little not great because it still required, you know, connecting with these private insurance companies that were just in this new network, right yeah, the marketplace, that's the market the marketplace. So it's still not even close to resembling what other countries have and
have had for many, many years. And it's also something that is for whatever reason and very controversial and seems to be in the process of being shut down, or at least attempted to be.
Yeah, it goes back and forth just because there is so much money here. We have it later in the episode. But maybe one of the things you have to consider now when you're playing along at home, folks, is that as an industry in the United States, healthcare is by far the number one employer, and that that is as of March twenty twenty five. Went back and forth between that and retail or even I guess the Pentagon is technically the largest single entity employer, but not anymore well
healthcare industry, Yeah, it's all the other companies. Oh no, yeah, God, I haven't even thought about all the stuff that's gonna happen rip to the stock market. By the way, I guess there's no prior approval on whatever surgery was needed for that one.
Ah, the patient's just stuffering for a minute and then it's going to heal. I mean to be fine, but to be fair, y'all, we've seen corrections before. We've seen you know, recessions before. I'm not trying to diminish what's going on, but also I really trying not to be utterly doom and doom about it.
Cool, that's good.
I stuck the mental health thing, guys, I'll go on to call it, call it willful self decepsion if you must. But this is where I land.
I had a I had one of those moments where I said, you know what, I'm just not going to look at anything like a four four A one K until twenty twenty nine. Get yeah, exactly.
So let's let's also just state here most of what we're talking about, if not everything we're talking about right now, have to do with insurance companies. So all the patients to the provider to the insurance company. The insurance company is the most important thing. These are private entities that
are for profit entities. Right There are other medical plans that you may find yourself getting if let's say you were you were formerly a member of the military, if you don't reach a certain level of income on a yearly basis, you could be a part of a federal or a state like medicare system, et cetera. That they function very differently than the ways we're talking about this
whole system. They're still attempting to cost cut right and sure and save get some savings wherever they can, but those systems are much less likely to have this type of system in play with the denials we're going to be talking about today.
Right right, especially the rate of attrition here, which is going to be key.
Now.
We gave the the theoretical defenses, right and god knows, nobody wants an innocent person to die because somehow the medicine that they should have gotten has been, you know, funneled off to someone who doesn't need it. Everybody agrees on that point, but it is is it not an argument of convenience because practice prior approval gets super dicey. We'll talk about the rules and criteria, and before we do that, we have to establish this is a hodgepodge
of incongruous, sometimes conflicting bureaucratic regimes. States have their own different laws regulating the process and what indeed should even be reported about the process. And the most important thing. I feel like we get lost in the banality of evil here, But the most important thing to remember when folks are navigating this arcane system is that there is often a ticking clock involved not getting a medicine, not
getting a procedure or treatment can lead to disaster. It is not as if your failing kidney is going to wait on your insurance company's paperwork. You know what I mean. You can't tell a bodily function or an organ of yours that you didn't fill out form XYZ correctly. The heart's not going to go now. Yeah, okay, well I'll keep taking along for ninety days.
That is a great point, Ben, because it is human beings that are potentially on the brink of death or you know, extreme extreme illness or pain. Yes, right, And as we found out last year, sometimes that denied back surgery could lead to a homicide.
So you know, we're learning, Luigi Mangio.
We're learning that this is the stakes couldn't be.
Higher here, And I really appreciate that because that foreshadowing is one of the crucial mission critical larger contexts that want us to get to at the end, because this occurs in situ with this stuff in media arrests. What is medically necessary quote unquote If you ask most insurance companies or insurance company adjacent things, they will say medically necessary means that when a doctor tells us or puts in a request for insurance to cover this thing private insurance.
Then we have to know for sure that the recommended treatment from the physician is proven to be the best current approach based on the most current verified research.
Again, that's also that there's not a cheaper alternative that will have quote the same outcome.
Right. They want to make sure something's not getting duplicated, and that can happen if you're seeing multiple specialists, right, One one specialist request an X ray, another one request an X ray, So an insurance company will say, hey,
we've already got an X ray. The economical option, or what we'll call lowballing, it occurs when just simply put, there are two or there are a couple of drugs that could treat a condition or a specific aspect of a condition, your doctor, for one reason or another, recommends one that is more expensive. The insurance company you will then ask your physician, why can't you just go with
the less expensive version. That's not an automatic denial, but that does mean your doctor, who's already very busy, has to justify why the more expensive option is better. Right, Is it because the pharmacy far is it because the pharmaceutical reps bribe them?
Which which is a potential thing. But then you create a situation where that physician has to spend hours on the computer typing up the reasoning behind something right that they just as the physician and as a care provider, said hey, this is what needs to happen.
Right, and you can appeal these denials. You can resubmit paperwork. A lot of times, it's the bureaucracy that gets people. You might have some kind of other quite innocuous error. So if you ever get denied for one of these prior approval requests, the first move you and your physics team are going to make is to try again. And there are cases where someone got denied for something twice thrice, only to get approved the third or the fourth time.
It for a long time, a huge issue with this was that these just like how the laws go state by state, each private insurance company in the United States had their own different systems, their own kind of formatting for things, their own kind of reasoning behind how we evaluate medical necessity. So what flew with like your I'm just making stuff up, but like what flew with you know, casadea United might not fly with shoe feed incorporated.
Well, and it's just I don't know. It's just kind of mind boggling that it's not more standardized, and it just really points to the problem of how having all of these separate entities kind of making their own rules without much cohesion between them, really is tough when it comes to like human health and human life and well being and being treated humanely, because so much of it feels like a crap shoot. The idea of getting approved the third or fourth time.
Why well, we'll get into it. But I think the real problem is that each of these entities is looking at the bottom line, and each of these entities, especially at the very top of the private insurers, are trying to make sure the total revenues for that year or that quarter are higher than the ones that they were before.
Yeah, you could also argue that their primary patients are the shareholders. Is just wild.
I'm sorry. I mean, I don't understund naive. It's just I know this is how capitalism works. But when you have such a capitalist, you know, philosophy behind something as important as like saving human lives, it's just yeah, it's wild.
It makes you wonder what the American Medical Association, it's four Besides lobbying, I guess or the.
Many other related medical associations. I love what you were saying. There no the idea of this massive discrepancy, these competing, sometimes contradictory systems. There's a solution, Dylan, if we could get some fanfare perfect set about large scale automation courtesy of companies like Core.
Right right.
The idea is uniformizing the approval process. Supporters will say, look, this saves cost, it cuts confusion overall. While imperfect, it is a better system. However, critics will say this system is purposely, brutally designed to deny as much coverage as possible, accelerating profits while you know, endangering or even ending human lives.
And we'll get into more about how that happens after a quick word from our sponsor.
Where it gets crazy. All right, evil Core, Evcore, Evycore.
However you they say, eviCore our corporate video.
All right, Well, we've given them the respect they're due. So evil Core is founded in the early nineteen nineties. It's a medical imaging company, you know the kind of folks who work with cat scans and X rays and stuff. This is nineteen ninety two, and it goes through several different headquarters like back and forth from South Carolina and Florida, et cetera. It goes through acquisitions. There's a merger in twenty fourteen, and the product of the merger is ultimately
acquired by the gigantic company Signa in twenty eighteen. And so now this is unnecessarily complicated, right, This company operates through eviCore operates under Signa with relative autonomy because they operate under a another subsidiary of Signa called ever North. So yes, it's Petroshka Dolls, right, that's partially to help out with accounting, to be quite honest with.
You, Yeah, it's really fun to go through those companies and then just see what all the mission statements are for the companies. As you imagine going down and parsing the mission into a sharper thing. I guess as you get, you know, through ever North, through Signa to ever North, to to eviCore.
Which is dance of euphemisms.
Oh yeah, which is now in Franklin, Tennessee. Everybody head quartered.
Tell them we said hi. So Evicore's best known thing the platform we're talking about tonight, along with thirty eight other huge clients of theirs is something called in telepath. In telepath, which sounds like a weirdly specific superhero power, I'm not a telepath, I'm an intell past that's funny.
I only read smart people's minds.
We got there. But the idea is that this proprietary platform can get things approved faster, can at least get decisions made faster, reducing the burnout of doctors. Overall, their argument is this makes things more efficient and less stressful for everybody, including patients on the ground who already pay these insurance companies a ton of money.
Well, you could certainly argue or see the merit in something like this. It all just depends on the rubric that it's using, you know, and then which sign it favor and which ultimate outcome is prioritized for the folks programming the platform or the very least nudging it in whichever direction.
What's the dial?
Oh, we're going to learn about the day dial. But if you want to put yourself in maybe you're not a medical provider or a physician, but if you want to put yourself in the shoes of somebody, let's say you're a doctor that you go and see on a regular basis, Evicre on their website has a nice little author pre authorization or they call it prior authorization checklist where you can see just all the things you need to do as a provider to provide to this thing
that we're talking about, this automated service, and then all of the different steps you need to take as that physician just to get a single prior authorization done.
And it is.
From my eyes, it's infuriate, infuriating the amount of busy work that somebody has to do to make one surgery happen.
Which is why there are entire small armies of support staff who has who have to walk through this stuff. You know, and keep in mind again we are make no mistake, we are talking about potentially life saving services. Now. Evicor can't get in too much, too much trouble for this as an insurer because it is not itself a direct insurer. It is a third party. Your insurance companies are outsourcing these approval decisions to companies like Evicre or
evil Core, and these clients. It might sound small when you hear these folks say, hey, we started with like three clients and now we have thirty eight. But those clients each one. They comprise some of the biggest insurance companies in the United States. So as a result, the partially automated approval decisions from this company, this outsourced third party, they affect around one hundred million people in this country as of last year. That is about one and three Americans with insurance.
Yep.
So if you've got oh, I don't know, Blue Cross, Blue Shield, Etna, United Healthcare, you were, or even some Medicare or some Medicaid groups use this service.
Yeah, I mean, and this is Look, this did not come out of someone's fever dream one night. This is the culmination of a massive decade long, multi decades long campaign by existing insurance companies because they looked around and they saw some studies that are again sort of convenient, and they said, all these healthcare costs are exploding, all these people getting over treatment. That's the euphemism over treatment.
That's not healthcare costs for you and me and us and the human beings. That's healthcare costs for healthcare corporations.
And again, though I mean, like this centralized platform that we're talking about, it would if used kind of more humanly, I guess be the thing we were saying maybe needed to happen some sort of standardization between these companies. But what it's trying to do is just not that's exactly the opposite of what we want, right.
It's so weird because the idea is that this company, like, okay, you're an insurance company, you outsource, you sign one of two types of contracts with this company, and as a result, they will somewhat automate the decisions or they'll they'll offload
the decision making process from your company. They specialize, ever Acorse specializes in expensive or niche procedures and recommendations, so oncology, gastro entrology, sleep problems, a Baker's dozen of other specialized fields like cardiology, course, and the idea is kind of what you were describing there. Know that this proprietary platform in Telepath streamlines everything in a single application. It manages requests,
clinical surveys, and it gives you real time decisions. That real time decision aspect is a game changer, especially when we're talking about time sensitive stuff, especially if those requests get approved. And that's the problem we can't thank again, k Dog and our pals at pro Publica and Capital Forum, we can't thank them enough for the fantastic work they published in October of last year. It's a long breed, but everyone should check it out.
It's huge, Yes, but dang is it intense. You can Yeah, you can find it everywhere. I think CNN even reposted it when it's like word for word, Yeah, exactly, a couple other places that our big publications put it out because it is that important.
Yeah, and they're saying they're saying what we've been sort of saying here at the top. Their investigation indicates that this company and companies like it's there are more than one in the game. They may be incentivized by more than just efficiency. They may be pursuing profits for clients by increasing rates of denial and doing so knowingly. And they don't even call it denials. They call it inappropriate care intermentrop say.
Guys, we talked about overtreatment, but ben, I think we skipped over the actual stats there of what is stated by the health insurers in like why they're looking for this service. Can we just hit those real quick?
Yeah, they said something the overtreatment rationalization right from the insurance companies are a handful of studies that if you read them are a little bit dodgy. We're not experts, but they're a little dodgy. They're claiming that twenty to forty five percent of certain medical treatments are ineffective, wasteful, or unnecessary. Forty five percent is a really high number, especially considering that the people making these requests have gone to medical school forever.
Dude, Yeah, well, and just this concept that, oh, well, we checked out patient a's heart because patient A was complaining of you know, heart issues. These are symptoms that someone who might have a heart attack soon would have, so we checked out his heart. Is that wasteful? Is that unnecessary? Because he wasn't actively having a heart attack? Right.
We talked about that too, you know, like, how do you That's such a devilish thing how one defines necessity? Right, someone's blood work comes back right, indicative of a possibly serious symptom. It's the sort of thing that as a physician you are ethically required to look into. It is your job to do that, and instead they're insured comes to you and says, well, this is going to be unnecessary. Or a few years ago, people did these blood tests, and this percentage of people did not in fact have
that dangerous condition. So roll the dice, you know, pick a card. Yeah, because it's probably not going to be the dangerous one. Request denied stamp, like denied stamp.
Sound already you can see how it feels like betting on human lives already. And we haven't even gotten to the details yet.
No, we've got to. We've got to talk about the dial, all right. This is the partially AI powered algorithm that makes the initial call your doctor. You know, someone comes in and they say, I'm having shortness of breath. I'm having you know, maybe like fugue states something like that, or heart palpitations, and you put in a request for some stuff. This AI powered algorithm is not a set in stone system the thing that replies. It's referred to the dial because it can be adjusted. I want to
be careful how we say this. It can be adjusted in a way that in practice raises rates of denial.
Yeah, yes, yes, and and and specifically that has to do with the type of contract EVI Core ends up signing with whatever insure other entity, right, because Ben, you mentioned there's at least two types of contracts. One of them is like the general we're gonna we are going to handle your prior authorizations through our system. Then we'll just do the whole thing of back and forth if we need to appeal the other one that you talked about.
There's a great example within that Pro Publica article of Uh, well, I'll just I'll read directly from the article. Uh, you can check it out if you want. The title of it is not medically necessary. You can just look that up probably and find it Pro Publica.
You'll find it.
Oh and is it? Is it okay if I shout out the authors there?
Oh?
Yeah, this is several Yeah, because they're there. This is like a posse track. So we're talking about t Christian Miller from Pro Publica, Patrick Rucker from Capital Forum, and David Armstrong also of Pro public journitists exactly.
So this is a direct quote from that. They're talking about these known risk contracts, which is a separate type of contract. They say, as an example, say an insure spends around ten million dollars a year on MRIs if eviCore keeps costs below ten million dollars per year on MRIs.
eviCore as a corporation, as an entity, pockets the difference in how like basically how much money that insurance company saved on MRIs that year according to that contract, or it might split those profits like fifty to fifty sixty forty something like that, depending on the contract with the health insurance company.
So isn't that like a kickback?
Yes, it's it's loosely called a risk contract.
Yes.
Former employees speaking under anonymity, called it.
Betting on future or something.
It's very much so, I mean that's the that's the other thing.
Right.
So the argument that there may be incentivization that moves you beyond just efficiency. It goes to look the contracts that have been verified by the investigation. They do indicate company profits can be tied, like you were saying, Matt, directly to the amount of cuts made and expenditures. Now,
the insurance companies have agency in this. The contracts that they sign can direct can direct this company and others like it toward focusing on certain not just outcomes, but certain conditions, certain medical conditions like now you're going to be our oncology approval gang. Right, And so some folks may argue, hey, this is just a matter of perception, because companies that are baking in this relationship between denials
and profits. They might just be trying to get stuff up and running that's better than their own older approval methods. Those may have had a lot of room for error, you know, and a lot of people were working with antiquated paper based systems.
Oh yeah, absolutely, But to really dial down on it, Oh god, sorry, I'm so sorry that this dial thing that is referenced a ton throughout that investigation, which is direct, which is essentially the algorithm that we're talking about here, it can be, according to a lot of those insiders,
really turned right. So you could say the insurance company actually needs to save x more percentage on those MRIs or something, and you could adjust how it looks at these prior approval documentation, the documentation for each individual one. And it's talking about how it can deny claims that have like a ninety five percent necessary rating or something.
Ninety five percent or less likelihood of approval. Yeah, yeah, yeah, And this is before we get to that. I got to I gotta say, I want us to put the claims of evicre in in context with the claims of critics and the claims of investigators. So you've got it, folks. While you're on the internet. There is a webinar from eviCore because yes they have a YouTube channel. Check out
ours as well, Conspiracy Stuff show. So in this video there's a spokesperson for evicre who says, yeah who who portrays client profits as not the primary goal, but as kind of a Bob Ros Style happy accident. And we love to love to play a clip here, Dilan if we could.
Not being exposed to things that they don't need to be exposed to unnecessarily. So we are improving the quality of health care, the safety of health care, and by a very happy coincidence, we're also decreasing a significant amount of unnecessary cost.
The line he says, I think is really important is, by very happy coincidence, we're also decreasing a significant amount of unnecessary cost. Woops, says the guy flying the plane. As a side effect of this plane, it turns out it flies, and of course, if you want to if you want to see that. Specifically, we're big fans of the titles and the Evicore's or Evcore or evil Core, because I'm not going to give them too much respect.
We're a big fan of the titles and their webinars that comes to us from retain and grow your self funded business with effective utilization management three years ago.
Yeah. You can also find an update too that they put out pretty recently on their YouTube that has the same kind of language, not quite exactly the same, but search understanding Evicore's approach to patient centered care.
So is this really a happy accident? If you go to back to pro Publicans and related investigations, you'll say, you'll see that what representatives of this company are saying internally does not match what they're saying externally. I'd love for us to go to a quote from pro Publica directly.
eviCore markets itself to insurance companies by promising a three to one return on investment that is, for every one dollar spent on eviCore the system, the insurer would pay out three dollars less on medical care and other costs. Of of course, salespeople have boasted of a fifteen percent increase in denials, according to the investigation, which is based on internal documents, corporate data, and dozens of interviews with former employees, doctors,
industry experts, healthcare regulators, and insurance executives. I mean, y'all if you took the first part of this lift from this quote from the article eviCore market it self to insurance companies by promising a three to one return investment. It sounds like the kind of thing that they would do as a sales pitch, you know what I mean, Like.
Yeah, it is yeah, one hundred so one hundred percent that yeah, And we know that because former salespeople, I guess legally I can't say they're former salespeople. Former employees confirmed this in some very high level ones. We also know some disturbing stats because again, remember how we're saying earlier, state by state laws change. Some states require denial rates to be a matter of public record. It is crazy
that not every state requires that. But with that, armed with that information, we can give you another stat here, pulling from evicuor's own self produced data, they fully or partially turned down around twenty percent of all request for medical care in Arkansas, So twenty percent, so one out of five of every request. And for comparison, people in that same state who were in Medicare advantage, about seven
percent of their claims would be rejected. So this shows us a big discrepancy between the business as usual and whatever innovations we could call them evicres bringing to the table. So to understand what's going on, we have to go back to the dial. Dial it back to the dial and maybe take a break for a word from our sponsors and walk through this claim process step by step. What do you guys say?
Oh, but yes, we should do it.
Sorry I sounded too excited. Let's do it.
And we returned the dial of denial. Not proud of it, but it's there.
That's worse than the dial of destiny, imaginarently, but it is a dial of it's true.
Really good point, Yeah, it really is. So Okay, you're a doctor. What's a good name for a doctor?
Oh?
Doctor? Spashuman doctor? Oh yeah, yes, yes, uh all right, so submit some paperwork, right, and this goes to the system. This goes to the dial, and the dial which is it's an informal name. By the way.
Uh.
The dial can automatically approve a request or it can flag it for further review. I think one thing a lot of people need to keep front of mind. Here is the dial, the AI power powered algorithm itself. It cannot as of yet, automatically deny a claim. It can only pop a flag and send it to a human.
Yep.
You will hear that as like rhetoric coming out from people that you know rightly see major issues with this and talk about how things are getting automatically denied by this algorithm. But you're absolutely one hundred percent right. It says that over and over in the investigation.
Yeah, it look where it is an important note because we do have to be fair. Anything it flags as not entirely kosher gets sent to an internal team of evicre nurses and doctors, some full time, some consultants. Only the doctors can issue that actual final denial, but all along the way, depending on the nature of the contract, the conversations with execs and shareholders, people in EVICORPS can adjust the settings on the system. They can dial up or down what rates as an automatic approval.
Yep.
Oh, and just to have Evicor's back a little bit here, guys, according to their videos that they put out, they let everybody know they only hire doctors for these purposes who are going to be doing the denials or approvals, who have had medical experience, like actually worked in a hospital or some similar practice.
Oh no, somebody like ethics degree. Isn't going to let me get in there, you know, underwater basket underwater basket weaving PhD.
Is it going to work for this ethics degree? All right? That sounds I wish more people had one of.
Those philosophy major doctor exactly.
Oh god, there's so many airplay jokes that could make. But anyway, okay, just one.
All right.
So somebody's having a heart attack there on the plane and the you know, the flight attendant says, is there a doctor in the house?
Anyway? It goes, no, I'm not a doctor. I just play one on TV. There it is.
Uh So, this algorithm gets that paperwork, it analyzes it, it assigns it what we could loosely call a likelihood of approval, knowing what we know in the past, based on the guidelines that we have generated internally, how likely is this thing to be a yes? One request could get rated at sixty or seventy percent, and depending upon where the algorithm is set, maybe if it meets seventy percent,
it gets automatically approved. Because now there's the argument would be fighting for that thirty thirty percent possibility of being denied. It's not worth our time it's not cost effective. But if the company wants more denials for a certain contractual relationship, they can dial that threshold up, like you were saying, Matt,
to something around ninety to ninety five percent. So when you think under that likelihood gets flagged for review and it goes to those internal employees, and the more reviews, the higher the chance of denial due to the nature of the internal guidelines.
This is just it's so infuriating, and you have you know, if you look at the outward statements for anyone who you know is going to be talking about this that has their job on the line, let's say it works for eviCore in any capacity or is is in that chain anywhere from the healthcare company down to the physician.
You you can imagine that nobody is going to come out and say, well, I'm incentivized to deny the things that are even at ninety percent ninety five percent approval, I am incentivized as a physician working for Evicre to stop that from happening, because if I stop that from happening, I'm you know, I'm going to keep my job. The
company's going to make more profit. The healthcare insurance insurance company is going to make more profit, and then somebody might have a big, big problem, you know, with their health.
It's one of those things too, where it's just they kind of tweak it just enough, it would seem where it's not like you could trace doctors getting paid off or like an incentive of you know, a bonus of some kind of four denials. But in a roundabout way, what it amounts to is more or less that in terms of like systematically the way this organization operates.
Yeah, because you can always say it's just for review, right, We're not immediately saying no, And then well we should get into the controversy about the guidelines. But yeah, that's the thing. When this stuff goes to review, the chances of it being denied are much higher. And then also you could argue they're foisting a bureaucratic burden upon the actual on the ground physician, upon the patient, anybody involved.
They've et acre evil Core has always said the system is built on continually updated guidelines, always based on the latest, most accurate research. And then they also say they go a step further, they say, look, these guidelines are sacked or sank to us, they're part of the system. They're state agnostic. The same stuff gets applied for all states, all clients. Someone requesting an MRI in Vermont gets treated the way someone the same way someone requesting an MRI
in Georgia would be treated. In short, they deny any and all claims. Get it of willful misconduct.
Hey, they deny all the claims, deny the Yeah, yeah, yeah. Just another quick quote from that investigation about those guidelines. And this comes from as you as we were saying, there are people inside the system speaking out talking about what they've experienced. This comes from they had to kind of mask it a little bit.
Uh.
This comes from an eviCore employee involved in the radiation oncology program. And the quote says company executives quote would say, keep a closer eye on the guidelines for reviews for aarticular company because we're not showing savings unquote for that particular company that they have a contract with.
And again, you know, the argument from that perspective is due diligence, right, But that's a big umbrella, and you can put a lot of villainy under that umbrella. And if we I've also want to point out the other the another issue that does not to be fair does not come from Evicors. But you know, we said evicre is kind of the Coca Cola. There are other brands in the game. One we could call the PEPSI would be under Elevance Health, a subsidiary called Caroline Medical Benefits Management.
They had to settle a lawsuit in twenty twenty two to the tune of thirteen million dollars because the courts investigated claims about claims concerning tactics they would use to deny approval requests. And one of the most villainous and petty like supervillain level of petty we found was this company has provably in the past set its fax machines to only receive five to ten pages at once, and it did not tell the customers. It did not tell
the physicians. What it would do is deny requests that were longer than the page count and say you didn't give us all the information, and someone at the doctor's office refaxes the thing, and then they get the same message back and get back on the phone and maybe eventually with some digging, they say, why is your fax machine like this?
Yeah.
In a quick note on that little company, from the investigation and just from general knowledge that we've learned on this show over the years. Elevant's Health used to have a different name. What do we know about companies that have to change their name of times? Once, twice, three times.
Come up with a joke about that earlier and I could. That's good, Matt, you did it. You got there.
They were anthem back.
And they were anthem. Yeah. Yeah, companies who look on this show. We always respect the preferred names and pronouns of individual people. But if you're a sketchy company, sorry, man, that first name is the scarlet letter. You earned it.
Pomecast guys, hey, it's been a weird channel.
Yeah, every all of them, you know, I know, I hope we should keep it on.
I think you're probably right.
Yah yeah, no, I mean for real, because the biggest one we talked about was back in the day, remember that contractor business, Yeah, changed your name at least three times, Xie academic. H Why did they change their name? Is just a rebrand right? Oh?
Wait?
No? Oh wait, no, there is think called WikiLeaks showed horrific videos of their contractors doing things.
So I need to continue today, yep, So just.
Remind yourself every time you see that rebranding thing, just what does it really mean?
Yeah, you don't have to automatically deny the potential goodness of that corporation, but you should flag it for personal review and see what their likelihood of approval is.
On your end, I'm seeing the seventy percent chance.
Sits for chicanery. There are Look, there are a ton of critics for this. It's pretty clear. You know, you mentioned multiple medical organizations they say the guidelines are kind of malarchy. And that's not just lobbying groups are all familiar with, but it's things like the American College of Cardiology, the Society for Vascular Surgery, the one I didn't know, but I think we'll all love this. When the American Society for Radiation Oncology or ASTRO. I think ASTRO is cool,
pretty cool. But the one thing these organizations all have in common is that they are experts in the in the conditions that this company approves or disapproves treatment for. These are the boffins. These are the eggheads and the experts, and they're the ones saying that the guidelines are crap. Yeah, I just want to point that out. You know, it's like, it's different from it's like if if the three of us actually built cyber trucks, are actually built pickup trucks
and said we didn't like cyber trucks. That's way different from us seeing one on the street in Austin and going uh huh, that's goofy.
That is it's very different. These are the people that actually know what they're talking about.
Have you guys seen a video of people using cyber trucks as skateboard ramps. It's kind of the perfect perfectly sometime. And also have we talked about the fact that they've recalled literally I think all of them beca because of this really dangerous metal strip that's just got glued on and that will just fly off randomly. Yes.
Yeah, if you're trying to save cost and per unit manufacturing, you can use the wrong adhesive and just have a no refunds policy. But luckily the US still has something like recall wawls.
Hopefully Healthcare doesn't deny your claim when that metal shrapnel flies off in traffic and slices your arm off or something.
Oh man, yeah, no kidding. Uh, there's another let's talk about the contracts too. There's another thing we have to mention. So in some of these deals there will be an agreement where we said evicor will guarantee a certain threshold of rise and denials right or rise and deficient or efficiency or whatever they call it. They'll also do a little bit of glad handing and they'll say, hey, if there are claims that are not denied, then we will
pay them. We the company, will pay the cost of those in exchange forgetting to keep any savings that we get beyond your standard expenses. This is part of the This is part of the tricky and ethically fraught thing, the risk contract. They have a flat rate contract, they have a risk contract. It looks like it makes the system not as objective as it would appear to be. And that's not us saying it. That's folks like the former California Insurance Commissioner Dave Jones, who has spoken about
this multiple times. Not just a pro public that's right.
Apparently doctors will sometimes be a bit more hesitant to send a request in the first place if they know the system is involved, the ev core system or core E of courses, the claim will get denied no matter what in this case, and Evicre internally refers to this as sentinel as facts or sentinel syndrome. Yeah, it sounds like something of X men.
Well, because you don't want to as the phys position or you know, that care provider. You don't want to get singled out and say, this person keeps pushing through all these things, we keep denying Where why are they being a problem?
Yeah, exactly, real drip. And then there's the other side, the way this company will portray it because they use the phrase sentinel effect as well. They'll say, think of it like how a sheriff comes to town, you know, and now people are a little more on their p's and ques. That's their argument. Again, your perspective may differ here, but this is the quick skinning. The US healthcare industry is a leviathan by any means, and it's we mentioned
as the biggest employer in the country statistically. That means, you guys, that a lot of us in the audience tonight tuning in are employed by this industry in one way or another, And that means it touches everyone in this country. Even if you have never filed a claim, even if you are in perfect health, this will somehow
reach you and your loved ones. So it's important for us all to ask, is this, knowing what we know now, is this genuinely a matter of reducing waste and making things more efficient or did these, perhaps once noble intentions, lead to a vast conspiratorial industry that is built to purposely prevent people from getting the care that, by the way they pay for, they're paying for us.
It's the most vexing part of all of it when you start like, even with these wildfires and things like I think we all have friends and colleagues of course that lost things in those and lost homes or were displaced, and just the attitude it would seem of the insurance company to do everything humanly possible to deny claims, especially after you've paid in all of this money, you know, for so so very long, and then you don't even
get the thing that you've been paying towards. It's really really disappointing.
It's baffling to see from Evercore's own website, in their own statements, from officials and board members and people who say things they give you the value add right, anytime anyone's going to pay for a product or service, what is the value that this product or service has for me.
The person who's buying it right in this case is the health insurance companies, and they're also you know, essentially giving a value add to the physicians and the care providers, saying, hey, we're gonna remove a lot of that junk you have to do all your busy work when you're getting these prior authorizations. But ultimately, to me, it's trying to fix a problem that's created by this insane system that we've built.
And every time we make these little changes to the American healthcare system, the private healthcare system, it is like putting band aids on leaking pipes, right, or pipes that have a gaping hole in them. We're trying so hard to fix something, but it just seems like, I don't know, guys, we've talked about before, it seems like the only way
forward really is to dismantle the thing. But if you dismantle the thing, as we said at the top of this, you're dismantling the largest like what employer base essentially that exists out there.
Yeah, yeah, and it is. It is a pickle. I always think it's best to think in terms of analogy to the point about whether the system itself is inherently beyond repair right as the car totaled. Think of it this way, Private insurance companies in this situation, just objectively, it is as though somebody owns a shoe store and they go to another company and they say, guys, these people who buy shoes too many of them are walking
out with the shoes they bought. Is there a way that we could, you know, make sure like fifteen to twenty percent of them don't leave with those shoes.
That's evil. That yeah, that's that's evil to the core. And let's also, hey, let's quickly point out here SIGNA Group on their website they boast about how they have one hundred and eighty point five billion total revenues at last time they checked.
Uh.
SIGNA Group. That's the people that own what's ever North that then runs this holostism we've been talking about the whole episode.
And SIGNA is using revenues in the plural correctly, because they're adding up the revenue from every arm of their.
Octopus exactly because they are the SIGNA Group, not just SIGNA Healthcare, which is a you know, international situation. But just think about that money that exists there, that money involved, and in the end, what is it for.
I thought you were going to go, Oh gosh, I thought you were going to do the song.
I almost did. It's just oh, it's given. I don't know I put it. It's given MANGIONI core to me, It's given core vibes. And you can just see, you can see.
Why have we mentioned that they're seeking the death penalty with old Luig.
That's yeah, that's how we're gonna wrap up. So it's like, yes, the these two companies we mentioned, they did get in trouble recently, just about two weeks ago, well over two weeks ago, as we record, on Friday, April fourth, and Anthem and Signat got in trouble with the Virginia State Corporations Commission. They had to pay back hundreds of people, but they had to pay back peanut fees. And this
further brings us to the context of Mangionics. Like you were saying, Noel, the Attorney General Pam Bondi, just a few days ago, just like this Tuesday, ordered federal prosecutors to seek the death penalty for Luigi Mangio, who, as we know, is the man I currently not convicted of gunning down United Healthcare CEO Brian Thompson in New York
City last year. He's twenty six, he's in jail. The population of the US overall versus the power structure of the US overall are deeply divided on this case.
I think we could the very least argue that he is sure as hell being made an example of.
Yeah, and he's also got an insane amount of support in the news. Also this, I think it was this past week, maybe the week before you're hearing this. Two weeks he put out a statement asking people to stop sending in so many photographs.
Yes, yeah, because Snell even talked about it.
Yes, And none of a support violence, none of a support you know, this kind of thing. But it's interesting, it's an interesting bellweather as to how so many people feel about the healthcare system and how clearly broken it is. It's just really kind of kickstarted again the whole conversation around it.
Yeah, please check out our series on Luigi. We explore the motivations for his actions, which are related to the idea of denying healthcare. During the research for this episode here, I think we were all unsurprised, but still moved to find how deeply these stories tie together. We may be looking at a sea change. You know, the Manngione case has exposed this great divide that always existed between the
average American and those in power. And as we're recording now, you know, we should also mention that he's got federal and state charges. So if state prosecutors bring their case first, he hasn't been federally indicted, then he could be imprisoned for life without parole or something to that nature. So that's still very much an evolving case, and in some case, some points it does seem like people would rather it be forgotten. I don't know, maybe that's where we end.
What do you guys think what's going to happen next?
I think this kind of thing only gets worse because again we're talking about trying to fix leaky pipes, but you've got whole sections of this thing that just don't even have any pipes, and there's just water filling up the submarine or whatever however you want to talk about it. It's just it's messed up.
I think we should only talk about it in nautical metaphors. I'm sorry, I'm joking. It's a really good one, Matt. I'm visualizing it, and you're absolutely right.
It's a sinking ship that is only serving the people who have life boats, you know.
See.
So continuing with I want to talk about something that a friend of the show, Charlie, brought up to me, which was that in a lot of states, if you don't make enough money, you can get on that state run medicare program. But if you all of a sudden cross that threshold because you got a new job and now you're making a little more money, now you're required to get healthcare through you know the what is it whether the marketplace? You have to get healthcare there, which
then those costs are in the hundreds of dollars. Before you weren't paying any money for your healthcare if you're on a state program or you know, the federal program, Now you have to pay, which means you're actually going to be making a lot less money on a month a month basis because you have to now pay into the private system. Like, how is that an okay thing? And how does that incentivize people to not get a better job?
Right?
And something we've talked about before, like this concept that's very popular in governmental speak, is a human being living off the system or something like that. Right, But we've designed a system that is going to punish people who aren't rich enough, right, or it's going to incentivize people to make sure they don't get too rich.
I don't know. It's just weird. It is weird. That's yeah. It's an interesting way of looking at it. That I mean, is it's how it is.
Yeah, something we had discussed previously, as as you mentioned. One thing that I think it's lost in a lot of the tribalization or politicization of things like that was calling the ACA Obamacare as a means of vilified it for people who didn't like that administration, when in fact it was generated by Mitt Romney very much as a conservative solution to the existing healthcare problems. Folks, this is where we're going to call it. Thank you so much,
as always for tuning in. I think it's always important for us to note obviously we cannot thank journalists like the good folks at Pro Publica enough for this fantastic, truly disturbing work. We also know that a lot of us listening tonight work in the healthcare industry aren't villains. It's the system. It's like stick said, it's deeper than skin. It's the system that they're keeping us in. Stick Man from Dead Press of course. Anyway, that's our group. Whuitous
hip hop reference. Gonna We're gonna call it an evening and we're off to noctivigate in the meantime. We can't wait for you to join the show. You can find us on an email. You can find us on a telephone. You can find us all over the internet, depending on how this episode goes.
That's right, and all of those places. You can find us at the handle Conspiracy Stuff where we exist on Facebook. We have our Facebook group Here's where it gets crazy, on x FKA, Twitter, and on YouTube where we have video content for your perusing enjoyment. On Instagram and TikTok. However, we're Conspiracy Stuff Show.
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