Migliaccio & Rathod LLP is investigating whether eviCore by Evernorth may have improperly denied overtime compensation to certain Clinical Reviewer Nurses and other utilization-management nurses whose work was heavily controlled by predetermined clinical criteria and standardized review procedures.
eviCore provides prior-authorization and utilization-management services for health plans across the country.
Its own careers materials describe RN and LPN Clinical Reviewers as reviewing requests for authorization, comparing those requests against “established clinical protocols,” approving requests that satisfy the criteria, and referring other requests for additional clinical review. Critically, eviCore states that when the criteria are not met, the Clinical Reviewer refers the case to physician review.
That means a nurse may be responsible for determining whether a request satisfies eviCore’s rules but may not have authority to independently make the ultimate adverse decision when those rules are not satisfied.
Clinical Reviewers May Have Been Required To:
- review requests for prior authorization;
- compare medical records against established clinical protocols;
- use eviCore clinical guidelines and electronic review systems;
- approve services when predetermined criteria were satisfied;
- refer cases to physician review when the criteria were not met;
- handle substantial daily volumes of cases, calls, or authorization requests;
- satisfy turnaround-time and productivity expectations; and
- document each review in eviCore’s systems.
eviCore maintains extensive clinical guidelines used to establish medical necessity across numerous categories of treatment, and its own clinical materials contemplate physician review for cases that fall outside specified criteria.
Why Overtime May Be Owed
A professional job title does not by itself determine whether an employee is entitled to overtime.
Migliaccio & Rathod is investigating whether some eviCore Clinical Reviewers were treated as exempt even though their day-to-day duties largely involved applying company-created rules to a high volume of authorization requests, rather than independently determining whether treatment should be approved or denied.
The distinction may be especially important for nurses who were expected to process dozens of reviews or calls each day and who could approve cases satisfying the criteria but were required to escalate cases that failed the criteria.
Potential Claims May Include:
- unpaid overtime under the Fair Labor Standards Act;
- improper classification as overtime-exempt;
- unpaid wages under applicable state law;
- failure to accurately record hours worked; and
- liquidated or statutory damages.
Signs You May Be Affected:
- You worked for eviCore, Evernorth, or Cigna as a Clinical Reviewer RN/LPN, Nurse Clinical Reviewer, Prior Authorization Nurse, Utilization Review Nurse, or similar employee;
- you were paid a salary and did not receive overtime;
- you regularly worked more than 40 hours per week;
- your reviews were based primarily on established clinical protocols or computerized criteria;
- you could approve requests that met criteria but had to send cases that failed criteria to a physician;
- you were expected to complete a particular number of cases or calls each day; or
- you performed charting, case review, or other work before or after your scheduled hours without additional pay.
If you have encountered these issues, we would like to hear from you. Please complete the contact form on this page, send us an email at [email protected], or give us a call.