CareCore National: Prior Authorizations Approved to Meet the Contractual Clock

The CareCore National prior authorization settlement required CareCore to pay $54 million over its practice of approving diagnostic requests without completing the required medical review. The company admitted that Clinical Reviewers approved requests awaiting physician review without new objective medical information or an independent Medical Director review. For someone working that queue, the change was concrete: a request that still needed a physician’s judgment went to the insurer as approved because its processing time was running out.

The Justice Department announced the settlement on May 11, 2017. It described CareCore National LLC as a benefits-management company then part of eviCore healthcare. CareCore reviewed diagnostic-procedure requests for insurers serving Medicare Part C and Medicaid beneficiaries. Its place in Medicare Advantage fraud was the approval that helped a claim get paid.

What CareCore’s Prior Authorization Review Was Supposed to Do

CareCore screened requests for medical reasonableness and necessity on behalf of health insurers, including managed care organizations. Its Clinical Reviewers, generally nurses, received information from treating physicians and entered it into CareCore’s proprietary software. The software recommended approval or further review by a physician.

Requests that could not be approved on the information supplied went into an electronic Medical Review Queue. A CareCore Medical Director, a physician retained by the company, could examine the request there. That review could include a peer call with the treating physician or an assessment of information gathered after the initial request.

The PAD Program Approved Requests as the Deadline Approached

CareCore’s Process As Directed program, known as PAD, directed certain Clinical Reviewers to approve requests that had spent nearly their entire allowed processing time waiting for physician review.

The contractual incentive was immediate. CareCore had to issue determinations within fixed turnaround times, often as little as four hours for urgent requests and 48 hours for non-urgent requests. It faced monetary penalties for missing performance standards, including processing deadlines. The government’s account connects the company’s difficulty keeping up with incoming requests to its effort to avoid those penalties.

Management monitored the Medical Review Queue. When the volume awaiting medical review was too high for timely decisions on a significant number of requests, management directed certain Clinical Reviewers to approve them without obtaining or considering new medical information. CareCore then transmitted those padded requests to its client insurers as preauthorized.

A request’s age had become the reason to approve it. The company had a medical question waiting in the queue and a financial consequence approaching on the clock. PAD resolved the clock problem by sending an approval while the required independent review remained undone.

How an Approval Became a Paid Claim

CareCore admitted that it knowingly represented padded requests as appropriately reviewed, and client insurers provided coverage based on those approvals. The review company’s output became an input to the insurer’s payment decision.

CareCore’s admissions spell out what the approval told the insurer:

The managed care organizations would pay for procedures requiring prior authorization only when the authorization complied with their policies and procedures. PAD led to claims connected to the padded requests reaching those organizations for payment with federal or state government funds. The organizations actually paid claims associated with those requests.

The insurer received an approval carrying CareCore’s assurance about work that CareCore knew it had not completed. Taxpayer-funded programs paid claims after the safeguard meant to assess the procedures had been bypassed.

Corporate Policy, Training and Daily Executive Reports

The government’s complaint alleged that improper approvals began as early as 2005. CareCore admitted that it formalized PAD as corporate policy in 2007, with detailed training materials and daily reports to high-level executives counting the padded requests.

From 2007 through June 13, 2013, CareCore padded between 200,000 and 300,000 prior authorization requests.

For an insider, these are different views of the same practice. The Clinical Reviewer sees the approval instruction. A trainer sees how the instruction becomes routine. A manager sees the queue pressure. An executive receives the count. Each view helps explain how a review requirement gave way to a deadline throughout an organized process.

Why Oversight of Review Contractors Matters

Prior authorization puts a financial decision inside a clinical review process. Medicare pays private plans monthly for coverage, and plans use utilization management to assess services before agreeing to pay for them. A contractor can perform that review on a plan’s behalf, placing another company’s staff, instructions and incentives between the treating provider and the coverage decision.

The American Institutes for Research explains the business purpose in its 2026 report Medicare Advantage Fraud, Waste, and Abuse Policy Options. Plans use utilization management to assess medical necessity, manage spending and identify provider fraud, waste or abuse. CareCore’s clients had purchased a service that was supposed to perform that screening. The deadline penalty gave the vendor a financial reason to get a determination out quickly.

A separate June 2026 HHS Office of Inspector General study, The Three Largest Medicare Advantage Organizations Denied Requests for Long-Term Acute Care and Inpatient Rehabilitation at Some of the Highest Rates, shows why the contractor’s role deserves attention. Looking at requests processed in June 2024, OIG found that some contractors denied requests at higher rates than organizations handling review internally. Many contractor denials were later overturned by the plans when appealed.

OIG connected that variation to oversight:

The shared question is what the contractor’s review actually delivers. In CareCore’s case, the company’s own admissions answered it: the approval represented a required review that had not happened.

What an Insider Can See Behind the Approval

An insider who understands the queue can explain the gap between the review the client expected and the review the vendor performed.

A Clinical Reviewer knows why a request still needs physician review. A Medical Director knows the work that approval requires. If you worked in training, compliance or client operations, your knowledge of how the company described and delivered its service matters too. We work with that knowledge to connect the review practice to the company’s representations and the government money involved.

The Federal and State Settlement and the Whistleblower Case

CareCore agreed to pay $45 million to the United States and $9 million to the 29 states named as plaintiffs in the whistleblower complaint. The resolution covered federal and state False Claims Act claims.

A whistleblower brought the case, and the United States joined it. CareCore admitted what it did: the instructions, the skipped reviews and the claims paid afterward.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. CareCore’s case shows why knowledge of the authorization process can matter: a person who understands how requests move through the business can explain what an approval conceals.

You Know What the Approval Conceals

If you saw requests approved to clear a queue while required medical reviews went undone, talk with our whistleblower experts about the instructions behind those approvals. We build the case with you and bring in healthcare fraud whistleblower lawyers who understand utilization-management contracts and government-funded claims. You get partners who can connect the clinical workflow to the money and stay beside you through the case.