EviCore Stops Whistleblowers’ Bid to Revive Medicare Fraud Suit

Whistleblowers’ claims that EviCore Healthcare MSI LLC violated the False Claims Act by causing health insurance companies to improperly bill Medicare and Medicaid for physical and occupational therapy services were properly dismissed, the Second Circuit affirmed Tuesday.

SW Challenger LLC and two unidentified whistleblowers alleged that EviCore—which provided reimbursement determinations for medical procedures to insurance companies—directed reviewers to auto-approve all requests for treatment regardless of medical necessity.

They also alleged that EviCore used artificial intelligence systems to approve certain treatment requests based on flawed critieria. As a result, EviCore provided worthless services to the insurance companies, or at least failed ...