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Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023

A KFF analysis found that Medicare Advantage insurers processed a staggering 49.8 million prior authorization requests in 2023 — up from 37 million in 2021 — averaging more than 4 requests for every single MA enrollee.

• Insurers denied 3.7 million requests. Only 11.7% of those denials were appealed — yet 81.7% of appealed denials were overturned in the patient's favor, suggesting millions of initial denials were improper.
• UnitedHealthcare: 85.2% of denials overturned. Cigna: 86%. CVS: 89.7%. Centene: 93.6% — meaning only 6.4% of Centene's denials survived third-party scrutiny.
• Total prior authorization requests: 49.8 million. Total denied: 3.7 million (7% of all requests).
• If 81.7% of all 3.7 million denials are as wrongful as those that were appealed, that is 3 million victims of the Denial Echo Chamber per year.
• Services with high denial rates included home health (15%) and skilled nursing facility stays (12%).

Claims Denials and Appeals in ACA Marketplace Plans in 2023

Insurers on the ACA Marketplace denied 19% of all in-network claims in 2023 — nearly 1 in 5 medical services that were already performed by an in-network doctor were retroactively denied. UnitedHealthcare was above average at 33%.

• Consumers almost never appeal. Of the 73 million denied in-network claims, patients filed formal appeals for less than 1%. When they did appeal, insurers upheld their own denial 56% of the time.
• Insurers processed 425 million claims in 2023, denying 73 million in-network claims.
• The most common reason given for denial: "Other" (34%), followed by "Administrative reason" (18%). Only 6% of denials cited lack of medical necessity.
• Blue Cross Blue Shield of Alabama denied 35% of in-network claims; UnitedHealth Group denied 33%.

Consumer Survey Highlights Problems with Denied Health Insurance Claims

A KFF survey of insured adults found that nearly 1 in 5 (18%) reported having a claim denied in the past year. For those who experienced a denial, only 29% reported their "biggest problem" was ultimately resolved to their satisfaction.

• Among patients with a denied claim, 24% said their health declined as a result, and 24% said they were unable to receive care recommended by their doctor.
• 58% of all insured adults reported experiencing at least one problem with their insurance in the past year.
• Denials were most common for employer-sponsored plans (21%) and marketplace plans (20%).
• 69% of those with a denied claim didn't know they could appeal. 86% didn't know what government agency to contact for help.

Ballad Health Sues UnitedHealth Group, Alleging Medicare Advantage Manipulation and Harm to Patients

Ballad Health filed a federal lawsuit against UnitedHealth Group, alleging the insurer systematically denies, delays, or underpays for medically necessary care for Medicare Advantage patients. The first time Ballad Health has taken legal action against an insurer — called a "last resort" after years of failed resolution attempts.

• The lawsuit alleges UnitedHealth improperly uses a "blatantly flawed" AI model to override physicians and prematurely deny post-acute care coverage, leaving patients hospitalized longer than necessary and increasing their risk of hospital-acquired conditions.
• The suit claims UnitedHealth withheld "millions of dollars" it had previously agreed to pay for patient care, and alleges a pattern of overstating how sick patients are to collect higher government payments while simultaneously denying claims.

Estate of Gene B. Lokken et al. v. UnitedHealth Group, Inc. et al.

A federal class-action lawsuit filed by estates of deceased Medicare Advantage patients alleges UnitedHealth Group illegally used an AI model to deny post-acute care to elderly patients. A federal judge allowed the case to proceed on breach of contract and breach of implied covenant of good faith and fair dealing.

• The AI model, "nH Predict," is alleged to be "notoriously inaccurate" with an error rate over 90%. The suit claims UHG knew of these flaws but used the algorithm to override physicians' recommendations, leading to "worsening injury, illness, or death."
• UHG knew only about 0.2% of policyholders would appeal the AI-powered denials. When denials were appealed, over 90% were reversed — demonstrating the model's blatant inaccuracy.
• The suit claims UHG employees were disciplined or terminated if they deviated from the AI's "rigid and unrealistic" predictions, regardless of the patient's actual medical needs.

Judge Rips Insurance Company for 'Immoral, Barbaric' Cancer Denials

A federal judge recused himself from a case where UnitedHealthcare denied coverage for proton beam therapy to a child with cancer — revealing he himself had been diagnosed with cancer and was initially denied the same treatment by his own insurer.

• Judge Robert W. Schroeder III was diagnosed with base-of-tongue cancer in 2018. His insurer denied proton beam therapy initially; it was later approved after appeal.
• The case he recused himself from involved A.F., a child with Ewing sarcoma, whose UnitedHealthcare plan denied the same therapy. The judge found the parallel too close to remain impartial.

Read the CNN Article → Read the National Library of Medicine Article →

Senate Democrats Release Scathing Report on Medicare Advantage Denials

A Senate investigation into the three largest Medicare Advantage insurers (UnitedHealthcare, Humana, and CVS/Aetna) found the companies deny prior authorization requests for post-acute care at far higher rates than other care categories.

• In 2022, Humana denied post-acute care prior authorization requests at a rate more than 16 times higher than its overall denial rate for all PA types.
• UnitedHealthcare's post-acute care PA denial rate more than doubled — from 10.9% in 2020 to 22.7% in 2022.
• CVS and UnitedHealthcare both denied post-acute care requests at rates roughly three times higher than their overall denial rates.
• The number of CVS post-acute care requests requiring prior authorization increased 57.5% from 2019 to 2022.

FTC Accuses CVS, Cigna, UnitedHealth of Abusing Middleman Role

Following a nearly two-year investigation, the FTC formally accused the PBM units of CVS Health (Aetna), Cigna Group (Express Scripts), and UnitedHealth Group (Optum Rx) of anticompetitive practices that inflate drug costs and restrict patient access to medicines.

• The three companies control approximately 80% of the PBM market. The FTC's vote to pursue action was 3-0.
• Allegations include using complex contracts, rebates, and fees to steer patients to their own affiliated pharmacies and disadvantage competitors — increasing PBM profits at the expense of patients and payers.

DOJ Interviewing Former Employees About Medicare Billing Practices at UnitedHealth

The DOJ is actively investigating UnitedHealth Group's Medicare Advantage billing practices, with investigators interviewing former employees involved in coding patient diagnoses — indicating a deepening phase of the probe into how the company inflates risk scores for payment.

• The investigation centers on "upcoding" — whether UnitedHealth used in-home health assessments to add diagnoses and improperly inflate risk adjustment payments from Medicare by potentially billions of dollars.
• Previous reporting suggested these practices could have led to $8.7 billion in extra Medicare payments in 2021 alone — taken from American taxpayers.

Read the Fierce Healthcare Article → Read the Wall Street Journal Article →

Too Big to Fail? Lawmakers Are Eyeing a Breakup of UnitedHealth Group

Driven by UnitedHealth Group's immense size and alleged anticompetitive vertical integration, U.S. lawmakers and regulators are seriously considering antitrust action — including the possibility of breaking up the healthcare giant.

• UHG's Optum employs or is affiliated with roughly 90,000 physicians — making it the largest employer of doctors in the U.S. Optum also controls ~15% of the outpatient surgery market.
• Concerns focus on UHG steering patients to its own providers and pharmacies, using patient data anti-competitively, and using acquisitions like Change Healthcare to further consolidate power.

UnitedHealth Medicare Advantage Fraud Investigation

The DOJ is conducting a civil fraud investigation into UHG's Medicare Advantage billing practices — specifically whether the company improperly inflated payments by diagnosing patients with conditions that were not medically relevant or accurate ("upcoding").

• An HHS OIG report found UHG received over $3.7 billion from Medicare in 2023 for diagnoses made during in-home assessments and chart reviews that lacked follow-up treatment.
• Senator Chuck Grassley cited reports that UHG's inappropriate diagnoses resulted in $8.7 billion in extra Medicare payments in 2021 alone.

Following Ryan's Call, DOJ Launches Investigation into UnitedHealth

The DOJ launched an investigation into UnitedHealth Group's Medicare billing practices following calls from lawmakers including Rep. Pat Ryan — coming shortly after UnitedHealth announced staff reductions despite allegations of defrauding taxpayers of billions.

• Rep. Ryan called the alleged upcoding behavior "deeply disturbing" and potentially harmful to both taxpayers and seniors needing care.
• The investigation targets in-home Health Risk Assessments (HRAs) as the primary vehicle for inflating Medicare risk adjustment payments.

Justice Department Sues to Block UnitedHealth Group's Acquisition of Amedisys

The DOJ and Attorneys General of Minnesota and New York filed a civil antitrust lawsuit to block UHG's proposed acquisition of Amedisys, alleging the merger would substantially lessen competition in the home health services market across numerous states.

• The DOJ argued that allowing UHG's Optum — which already owns LHC Group — to also acquire Amedisys would harm vulnerable patients, including seniors and individuals with disabilities who rely on home health care.
• Alleged harms: higher prices, lower quality of care, reduced access, less innovation, and depressed wages for home health workers.

Trump DOJ Gives Monopolist UnitedHealth a Green Light to Swallow Yet Another Competitor

The Trump administration's DOJ settled the Biden-era antitrust lawsuit that was originally filed to block UnitedHealth Group's $3.3 billion acquisition of Amedisys — drawing immediate criticism that the deal represents political favoritism over patient protection.

• Critics including Senator Elizabeth Warren called the settlement "half-baked," alleging it allows UnitedHealth to divest required locations to "similarly conflicted buyers," including a private equity firm.
• The Biden-era DOJ had warned the merger would let UnitedHealth "further extend its grip" on home health care, "threatening seniors, their families, and nurses."
• A recent analysis cited in the article states that UnitedHealth Group currently has approximately 2,700 subsidiaries.

Change Healthcare Settlement: Proposed Final Judgment and Competitive Impact Statement

This document outlines the DOJ's settlement with UHG regarding the acquisition of Change Healthcare. To resolve antitrust concerns, UHG agreed to divest Change Healthcare's claims editing business (ClaimsXten) to private equity firm TPG Capital — allowing the main acquisition to proceed.

• The original DOJ lawsuit aimed to block the acquisition entirely because it alleged UHG (a major insurer) acquiring Change Healthcare (a critical data source for rival insurers) would give UHG unfair access to competitors' sensitive information.
• Legal basis: alleged violation of Section 7 of the Clayton Act.

NY Attorney General Takes Action to Protect Access to Health Services in Western New York

New York Attorney General Letitia James filed a lawsuit seeking a court order to prevent UnitedHealthcare from terminating contracts with Catholic Health System in Western New York, arguing the move would significantly harm healthcare access for thousands of New Yorkers.

• The termination would disproportionately affect seniors on Medicare Advantage and low-income individuals, removing in-network access to Mercy Hospital of Buffalo, Kenmore Mercy Hospital, and Sisters of Charity Hospital.
• AG James alleged UHC's action violates its obligations to maintain adequate provider networks and constitutes "irresponsible corporate behavior that prioritizes profits over patient well-being."

Mayo Clinic to Leave Most UnitedHealthcare and Humana Medicare Advantage Networks

Effective January 1, 2026, Mayo Clinic will no longer be an in-network provider for most individual Medicare Advantage plans from UnitedHealthcare and Humana — affecting patients at Mayo facilities in Minnesota, Wisconsin, and Iowa.

• In Minnesota, the number of insurers offering Medicare Advantage with in-network Mayo access will drop from five in 2025 to just two in 2026 — part of a larger trend that has Minnesota experiencing the second-largest drop in available Medicare Advantage plans in the nation.

Johns Hopkins and UnitedHealthcare Officially End Negotiations, Leaving 60,000 Patients Out-of-Network

After eight months of negotiations and five extensions, Johns Hopkins Medicine and UnitedHealthcare ended contract talks without agreement. As of August 25, Johns Hopkins facilities are out-of-network for most UHC members.

• Approximately 60,000 people in Maryland, DC, and Virginia are impacted — patients with employer-sponsored, individual, Medicare Advantage, and Medicaid plans all face higher costs or forced provider changes.
• The stalemate was reportedly not over money — both sides had agreed on financial terms. The dispute centered on contract language about patient care and denials.
• Johns Hopkins stated it would not agree to terms allowing an insurer to "prioritize profits over patients" through "excessive delays or denials" of care.

Read the Banner Article → Read the CBS News Article →

LVHN to Drop UnitedHealthcare Insurance Plans

Lehigh Valley Health Network (LVHN), part of Jefferson Health, announced it will terminate contracts with UnitedHealthcare in 2026 if a new agreement is not reached — citing UHC's failure to pay negotiated rates since 2021, resulting in reimbursement 40% below expected levels.

• Medicare Advantage contract ends January 25, 2026. Commercial insurance contract ends April 25, 2026.

Read the DelcoTimes Article → Read the LVHN Official Update →

'Not Sustainable': OHSU and UnitedHealthcare Near Contract Expiration

Oregon Health & Science University, a premier medical institution, warned patients it may be forced out of network with UnitedHealthcare, citing "administrative burdens" and denial rates that make it impossible to provide sustainable care.

Duke Health Could Drop UnitedHealthcare for 170,000 Patients

Duke Health is in a standoff with UnitedHealthcare that threatens to leave 170,000 North Carolinians without in-network access to their doctors — highlighting that even top-tier academic medical centers are being squeezed by insurer tactics.

M Health Fairview: 125,000 Patients at Risk

M Health Fairview warns that UnitedHealthcare's practices could block 125,000 patients from care — following a trend in UnitedHealth's own home state of providers pushing back against the giant.

Corewell Health vs. UnitedHealthcare: Michigan's Battle

Corewell Health, a massive provider in Michigan, is locked in a dispute with UnitedHealthcare. The friction points are consistent with national trends: insurers paying less while demanding more administrative hurdles that delay patient care.

USA Health Contract Expires: Patients Left in Limbo

In Alabama, the contract between USA Health and UnitedHealthcare officially expired — immediately thrusting patients into "out-of-network" status, facing astronomical bills or loss of care.

TriHealth Dispute: Cincinnati Patients at Risk

TriHealth in Cincinnati warns that thousands could lose coverage. The pattern is undeniable — regional health systems across the entire country are simultaneously reaching a breaking point with UnitedHealthcare's business practices.

LCMC Health: 30,000 New Orleans-Area Patients at Risk

LCMC Health and UnitedHealthcare entered a contract dispute threatening to remove 8 major New Orleans-area hospitals from UHC networks — impacting patients across employer-sponsored and ACA exchange plans.

• 30,000 patients affected. Hospitals include East Jefferson General, Touro Infirmary, University Medical Center, and West Jefferson Medical Center.
• LCMC claims UnitedHealthcare wants to pay well below inflation and far below competitor rates, despite LCMC being the "lowest cost provider across the region."

The "Downcoding" Epidemic: Aetna & Cigna

It isn't just UnitedHealthcare. A new explainer details how Aetna and Cigna are implementing aggressive "downcoding" policies — automatically lowering the severity level of emergency room visits to pay less, regardless of what the doctor actually treated. This is algorithmic wage theft against hospitals.

UnitedHealth's Optum Unit CFO Steps Down

Roger Connor stepped down as CFO of UnitedHealth's Optum unit after less than six months — the latest in a significant period of management reshuffling at UnitedHealth after the company missed earnings targets for the first time in over a decade.

• In the past year, the company has appointed a new group CFO, a new CEO of Optum, and new heads of Optum Rx (pharmacy) and Optum Health (clinics and home-care).

UnitedHealth Marked Up Lifesaving Drugs as Much as 1,000%: FTC

A class-action lawsuit filed in Minnesota accuses UnitedHealthcare, through subsidiaries Optum Rx and Accredo, of significantly marking up specialty drugs — sometimes by thousands of dollars per prescription compared to what the pharmacy actually paid — in violation of ERISA fiduciary duties.

• Alleged markup: dimethyl fumarate (MS drug) — from ~$200 Accredo paid to over $4,000 charged to the patient's plan.
• Alleged markup: lenalidomide (cancer drug) — from ~$300 to over $6,000.
• The lawsuit alleges UHC's PBM (Optum Rx) directs patients to its own affiliated specialty pharmacy (Accredo), creating a closed system for inflated pricing, while hiding the markups through complex contracts and lack of transparency.

UnitedHealth Accused of Overcharging for Drugs in Class Action

A federal class-action filed in Minnesota accuses UnitedHealth Group and Optum Rx of breaching ERISA fiduciary duties by orchestrating a scheme to massively overcharge employer health plans for specialty medications dispensed through affiliated pharmacy Accredo.

• Dimethyl fumarate (MS drug): allegedly acquired for ~$200, billed to the plan at over $4,000.
• Lenalidomide (cancer drug): allegedly acquired for ~$300, billed to the plan at over $6,000.
• Note: Accredo Specialty Pharmacy is owned by Cigna; the lawsuit alleges it collaborates with UHG's Optum Rx in this pricing scheme.

Knowing When and How to Fight Back: Protecting Independent Community Pharmacies from Overbearing PBMs

The top 3 PBMs — CVS Caremark, Express Scripts/Cigna, and Optum Rx/UnitedHealth — control approximately 80% of the prescription drug market and hold immense power over independent community pharmacies through network participation, reimbursement rates, drug formularies, and audit processes.

• PBM tactics include: Spread Pricing (charging health plans more than they pay pharmacies), reimbursements below drug acquisition cost, retroactive Direct and Indirect Remuneration (DIR) fees, patient steering, restrictive network contracts, and burdensome audits.
• Independent pharmacies often face a "take it or leave it" scenario with PBM contracts due to market dominance.
• Legal avenues include state PBM laws, state insurance departments, attorneys general, the ongoing FTC investigation, and arbitration or litigation for contract breaches.

UnitedHealth Group Resists Shareholder Proposal on Delayed and Denied Care

UnitedHealth Group asked the SEC to block a non-binding shareholder proposal that would require the company to report on the broader economic and public health costs of its practices that delay or deny patient care. The proposal was filed by the Interfaith Center on Corporate Responsibility (ICCR), representing institutional investors.

• Shareholders argued UHG — the 19th-largest company in the world — has such market power that its denial practices could harm the overall US economy by keeping workers sick, indebted, and less productive. More than 5% of US GDP flows through UHG each day.
• UHG argued terms like "public health-related costs" were too vague. Shareholders later withdrew the proposal after UHG challenged it twice, but stated they will continue dialogue with the company.

UnitedHealth Under Scrutiny for Nursing Home Practices — And a Family's Story

UnitedHealth Group faces scrutiny over accusations that it provided financial bonuses to nursing homes to incentivize fewer hospital transfers — with families and whistleblowers alleging residents' medical issues were concealed, delayed, or denied to protect profit margins.

• Nurse practitioner whistleblowers allege the bonus system led to "delays and denials of medically necessary care." Senators Ron Wyden and Elizabeth Warren have launched investigations.
• Vincent Cinque, whose mother and grandmother are both in nursing homes, says their treatment has been "halted for some time" and their experiences align directly with the alleged practices. "It feels like the system is designed to break us, to crack us, and to make us give up. But I don't want to give up on my Mom."

Read the NewsNationNow Article → Watch the NewsNationNow YouTube Coverage →

UnitedHealth Group Abuse Tracker →

Maintained by: American Economic Liberties Project (AELP)

Compiles news reports, legal filings, and analyses concerning alleged anticompetitive practices, patient care issues, and market power abuses involving UnitedHealth Group and its various subsidiaries across the healthcare industry.

HEALTHCARE — People Over Profit

The POPNYC healthcare page documents multiple "Deaths by Denial," providing specific examples of patients — including Little John Cupp, Nataline Sarkisyan, and Tracy Pike — who died after insurers like UnitedHealthcare, CIGNA, and Blue Cross Blue Shield repeatedly denied their doctors' requests for life-saving or necessary treatments, often deemed "not medically necessary."

• A 2023 class-action lawsuit alleges UHC's "nH Predict" AI algorithm has a 90% error rate but is used anyway — the company allegedly knows only a small percentage of patients will appeal.
• One "medical benefits management company" (EviCore) that insurers hire to deny claims advertises a 3-to-1 return on investment for those insurers.
• A 2022 survey of oncologists found 42% of prior authorizations were delayed, with doctors attributing "loss of life" to these delays 36% of the time.