The Hidden Rule Makers Behind Prior Auth and Claim Denials: How InterQual, MCG, HealthEdge, Zelis, Lyric, and Optum’s CES Write the Criteria Payers Use to Reject Care and Why That’s Where Real Reform

Everyone knows the payer’s name on the claim denial or prior auth denial letter. Almost nobody knows the names of the companies that wrote the rules behind it. That’s the real prior auth and claim denial story.

Two products sit underneath most prior auth decisioning in the US. InterQual (Optum-owned) at roughly sixty percent market share. Milliman Care G…