When an algorithm decides if health care is medically necessary.

From American Public Media, this is Marketplace Tech.

I'm Megan McCarty Carrino.

Some of the biggest health insurers in the country are turning to an algorithm to help determine if a medical claim will be approved.

That's according to a recent investigation led by ProPublica into EVECOR, a contractor used to outsource prior approval requests for much of the insurance industry.

EFECOR tweaks an algorithm to increase the likelihood those claims will be denied,

which means lower costs for insurers, but more patients losing access to potentially

life-saving care, according to T. Christian Miller, who co-reported the story.

Well, Evacore's a giant company. Almost anyone who's ever gone to the doctor and been told, nope, the insurance

company hasn't approved this, has probably interacted at some point in time with

EvoCore. EVECOR covers about 100 million people in the United States. That's about one of

every three insured people in the country. What they do is the insurance company, like

Aetna or Cigna or Blue Cross will send your case to EvoCore.

And EvoCore will actually look over your case and decide whether or not they're going to give approval to your doctor to get paid for the surgery or the MRI or whatever treatment that your doctor has recommended for you.

And as you found, EvoCOR uses an algorithm, which insiders you spoke to call the dial,

to manipulate coverage decisions. How does that work?

Yeah, that's a really interesting thing. Here's how that works.

So your insurance company will send your file to EVECOR, and EVECOR first runs that file through an

algorithm, and that algorithm decides whether or not to approve the care. So, for example, you go see your doctor,

the doctor says, hey, I think we need you an MRI.

That request will then go to the algorithm.

The algorithm will say,

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