Healthcare Room II
The Reason Room
The statistics in the Problem Room describe a mechanism. These are the people that mechanism ran through. Each story is documented. Each outcome is real. Each court ruling is on file.
Why these stories matter beyond tragedy
Every case on this page went to court. Every case lost — not because the harm wasn't real, but because courts ruled there is no law that covers it. Judges have called these outcomes "tragic" and "a travesty" while simultaneously dismissing the lawsuits. The Reason Room is the argument for why that legal gap must be closed. The Remedy Room is what closing it looks like.
Documented Cases
- Case I — Kathleen Valentini: The MRI That Would Have Changed Everything
- Case II — Christopher McNaughton: "We're Still Gonna Say No"
- Case III — Michael Kissling: Prior Knowledge Omission and the Cost of a Wrongful Denial
- Case IV — Katelynn Kissling: A Pediatrician, an Adult Patient, and the Same Mechanism
- The Broader Context — Public Reaction, Structural Analysis
More cases being documented. Share your story →
Case I
Kathleen Valentini
Waxhaw, North Carolina · GHI / EmblemHealth · eviCore
Kathleen Valentini with husband Val and son Matthew. Kathleen died in November 2020 at age 50.
The Story
Kathleen Valentini was, by every account, an ideal patient — diligent, proactive, and attentive to her health. When she developed worsening hip pain that physical therapy wasn't resolving, her orthopedic surgeon did what doctors are trained to do: he ordered an MRI.
Her insurer, Group Health Inc. (GHI), a subsidiary of EmblemHealth — operating through a third-party denial contractor called eviCore — said the MRI was "not medically necessary." The stated reason: she needed to complete six weeks of physical therapy first. GHI had already approved and paid for that physical therapy. The denial was issued against a medical history the insurer already possessed.
The doctor appealed. Forty-one days after the original MRI request, GHI reversed its denial. By then it was March 14, 2019. The MRI revealed an aggressive sarcoma in Kathleen's right hip.
The Timeline
Orthopedic surgeon orders MRI for worsening hip pain after physical therapy fails to help.
GHI/eviCore denies MRI as "not medically necessary" — requiring six weeks of physical therapy first. GHI had already approved and paid for that physical therapy. The history was in the medical record.
The doctor appeals. Forty-one days pass. Kathleen waits while the cancer grows.
MRI finally performed. Aggressive sarcoma confirmed in right hip. Kathleen travels to Memorial Sloan Kettering Cancer Center.
Sloan Kettering doctors deliver the prognosis. "Had you come to us a month sooner, we could have used chemotherapy. Now we can't. We have to amputate before we treat with chemo." Kathleen's leg, hip, and pelvis are amputated in a 20-hour surgery. While she is still in the hospital recovering, GHI continues denying tests.
Val and Kathleen Valentini file suit against GHI and eviCore, alleging negligence, medical malpractice, fraud, breach of contract, and conspiracy. The suit alleges GHI is "engaged in a systemic effort to delay or block necessary medical treatments."
Kathleen Valentini dies at age 50, leaving behind her husband Val and their teenage son Matthew. "I'm convinced that the delay caused her death. They deny and delay and hope you go away." — Val Valentini
US District Judge John P. Cronan dismisses the lawsuit. Finding: GHI had no duty of care to Kathleen. The insurance policy gives GHI the right to determine medical necessity. No physician-patient relationship existed with eviCore.
The 2nd U.S. Circuit Court of Appeals affirms the dismissal. The court rules that prior authorization review "is not a service that subjects the general public to possible physical harm when performed without care." The judge calls the outcome "a travesty" — and upholds the dismissal anyway.
What the Court Said It Could Not Do
"Preauthorization utilization review is not a service that subjects the general public to possible physical harm when performed without care — it is rather a service that ensures financial reimbursement of individual insureds for contractually covered medical services."
— 2nd U.S. Circuit Court of Appeals, 2023
The court acknowledged the harm was real. It ruled there was no law under which the insurer could be held liable for it. The AMA, the Vermont Medical Society, the Connecticut State Medical Society, and the Medical Society of the State of New York all filed amicus briefs arguing the opposite — and lost.
The Clinical Integrity Amendment addresses exactly this gap: by mandating that the physician who signs the denial is personally accountable for the clinical judgment they render — not shielded by the insurer's contractual structure. eviCore's own website promised it would "put patients' needs first." The 2nd Circuit said that promise was not legally enforceable. The Amendment makes the clinical standard legally enforceable.
Who Is eviCore?
eviCore is a "medical benefits management company" that insurers hire to deny claims. One source cited in the Problem Room notes that eviCore advertises a 3-to-1 return on investment to insurers who contract with them. Kathleen Valentini's denial was issued by eviCore on behalf of GHI — a third party with no physician-patient relationship to her, no personal liability for the outcome, and a financial incentive to deny. The Clinical Integrity Amendment's specialty matching requirement (§ 2) would require that any reviewing physician be board-certified in the relevant specialty. It does not currently specify the reviewing physician's name, credentials, or specialty at the time of denial.
Sources
Case II
Christopher McNaughton
State College, Pennsylvania · UnitedHealthcare / Penn State Student Plan
The Story
Christopher McNaughton was 20 years old, 6'4", playing college basketball at Bard College, when he returned from winter break in 2014 and couldn't stop going to the bathroom. Within days he was diagnosed with severe ulcerative colitis — a chronic inflammatory bowel disease with no cure. What followed was six years of his life effectively erased: up to 20 bouts of bloody diarrhea a day, severe arthritis, dangerous blood clots requiring hospitalization, loss of 50 pounds, and confinement to his parents' house in State College. For two years he ate the same meals every day — Rice Chex and scrambled eggs, white rice with chicken — because he couldn't risk anything else.
He worked through a series of failed treatments until a specialist at the University of Pittsburgh referred him to Dr. Edward Loftus at Mayo Clinic — one of the leading gastroenterologists in the country. Dr. Loftus found a combination of two biologic drugs at above-standard doses, an off-label regimen. It worked. For the first time in years, McNaughton could function. He enrolled at Penn State in 2020. He was attending class in person. He was living something like a normal life.
His medical bills were running nearly $2 million a year. UnitedHealthcare — which provided Penn State's student health plan — flagged his case as a "high dollar account."
🎙️ The Recorded Phone Call
In May 2021, UHC nurse Victoria Kavanaugh called her colleague Dave Opperman to share news about the McNaughton case. The call was recorded, as UHC routinely recorded internal calls. Through McNaughton's subsequent lawsuit, that recording became public.
Kavanaugh told Opperman that a doctor contracted by United had reviewed the case and concluded McNaughton's treatment was "not medically necessary." Opperman reacted with a long laugh. He then complained about McNaughton's mother, calling her "this woman" and mocking her for "screaming and yelling" and "throwing tantrums" on calls with United.
"We're still gonna say no."
— Dave Opperman, UnitedHealthcare, May 2021 (recorded internal call)
The pair agreed that any appeal would be a waste of the family's time and money — before the appeal had been filed.
What the Lawsuit Uncovered
- United buried its own doctor's report. A physician paid by UHC reviewed the case and concluded that denying McNaughton's treatment could put his health at risk. UHC did not consider this report. They did consider a report from a different company doctor who copied and pasted a nurse's recommendation and typed "agree."
- United misrepresented the treating physician's position. Court records show UHC inaccurately reported to Penn State and the McNaughton family that Dr. Loftus — the Mayo Clinic specialist — had agreed to lower the medication doses. Dr. Loftus had not agreed. He had warned that altering the treatment "would have serious detrimental effects on both his short term and long-term health and could potentially involve life threatening complications."
- The cost calculus was explicit. Internal UHC emails show officials calculated exactly what McNaughton was costing them and how much they would save by forcing him onto a cheaper treatment that had already failed him. The company said publicly the denials weren't about cost. The documents said otherwise.
- The case was monitored at the highest levels of the company. Despite the public claim that this was routine utilization review, UHC's internal records show McNaughton's case reaching senior leadership.
The Reviewing Physician — Dr. Cates Under Oath
Through the lawsuit, the reviewing physician — Dr. Cates — was deposed. His testimony is a verbatim description of exactly what the Clinical Integrity Amendment § 2 was written to prevent:
- Dr. Cates testified he had not treated patients with ulcerative colitis in his practice and had referred those cases to gastroenterologists — meaning he was not a peer of Dr. Loftus and had no relevant specialty expertise.
- His review of the McNaughton case "primarily involved reading a United nurse's recommendation to deny his care and making sure there wasn't a decimal place that was out of line."
- He copied and pasted the nurse's recommendation and typed "agree." He does approximately 100 reviews per week.
- UHC's policies "prevented him from considering that McNaughton had failed other treatments or that Loftus was a leading expert in his field."
"You are giving zero weight to the treating doctor's opinion on the necessity of the treatment regimen?"
— Attorney, in deposition of Dr. Cates
Under the Clinical Integrity Amendment § 2, Dr. Cates' denial would have been void from the moment it was issued — he lacked board certification in gastroenterology, he had not reviewed the full clinical record, and he had certified none of the submitted evidence under penalty of perjury. The denial itself would have triggered mandatory State Medical Board reporting.
Outcome
McNaughton filed suit. The lawsuit forced UHC to release its internal communications. Shortly after ProPublica published its investigation in February 2023, UHC settled. The terms are confidential.
McNaughton is still on his treatment. He is still enrolled in school. He has stated that he fears having to fight this same battle every year for the rest of his life — because nothing structural changed. The settlement resolved his case. It didn't change the system that produced it.
What This Case Proves About the Mechanism
The McNaughton case is the Wrongful Denial Echo Chamber with the lights on. Every element of the system is visible: the "high dollar account" flag, the buried favorable report, the misrepresentation of the treating physician's position, the reviewing doctor who copied and pasted a nurse's note, the pre-decided appeal outcome on a recorded call. This is not a case where the system malfunctioned. This is a case where the system worked exactly as designed — and someone happened to have the resources, the will, and the extraordinary good fortune that a national news organization investigated it and published. Most people don't.
Sources
Case III
Michael Kissling
Allentown, Pennsylvania · UnitedHealthcare Medicare Advantage
The Story
Michael Kissling was 27 when his doctors first identified May-Thurner syndrome — a vascular condition causing dangerous blood flow issues — and recommended an iliac vein stenting procedure with an 85–90% five-year patency rate. UnitedHealthcare denied it after extracting the out-of-pocket maximum for the imaging that proved its necessity.
Over the next several years, UHC also denied Apligraf — an FDA-approved wound care treatment cleared in 1998 and 2000 — for 17 months while non-healing wounds progressed. When Apligraf was finally approved, it closed the wounds in two weeks. It had taken 17 months and bone demineralization to get there.
On February 1, 2023, Kissling's leg was amputated above the knee. Pathology from the surgery described bone that had demineralized to a consistency "cuttable with a scalpel" — severe osteomyelitis caused by the prolonged wound care delays. His treating physician confirmed the amputation would not have been elective had the prior pathology been known; Kissling was "one bad step from compound fracture and death by bleeding out" due to his anticoagulant therapy.
The Prosthetic Denial — Prior Knowledge Omission Documented
Six weeks after the amputation, UHC approved a learner prosthetic — officially acknowledging Kissling's K3 functional mobility status (AMPnoPRO score: 35). This classification became mandatory knowledge in UHC's possession. Six months later, UHC denied the transition to a permanent tertiary prosthetic, claiming Kissling did not demonstrate sufficient functional ability to qualify.
UHC approves learner prosthetic — officially establishing K3 functional mobility status. This is mandatory knowledge in UHC's possession.
Six days after K3 establishment, UHC changes the beneficiary's plan — making all existing physicians and physical therapists out-of-network. Care continuity disrupted.
UHC denies permanent prosthetic — claiming insufficient functional ability — while possessing the K3 approval and an updated K4 physical therapy evaluation (AMPnoPRO: 44/47). UHC's reviewing physician explicitly refuses to acknowledge the K4 PT data because it was not written in his specific office note.
UHC final denial letter, signed by Senior Appeals Representative Christopher Toland, states: "Medicare Guidance says that the requested computerized knee advanced feet exceed your needs" — issued with documented prior knowledge that the patient was K3–K4, in direct violation of Medicare Policy Article A52496.
Maximus Federal Services (Independent Review Entity) immediately overturns UHC's denial. Finding: medically necessary. This overturn is equivalent to summary judgment — UHC's position was indefensible.
Medicare lowers the microprocessor knee standard from K3 to K2 — meaning Kissling would have qualified under even the future relaxed standard. UHC's denial had no medical or regulatory basis at any point in time.
The Smoking Gun — Dr. Stockhausen's Written Documentation
The attending physician, Dr. Sean T. Stockhausen, documented in writing that during the peer-to-peer review, the UHC reviewing physician:
- Confirmed he remembered arguing that the patient was K4
- Stated he could not use the objective PT data — including walking speed and AMPnoPRO score — because it was not written directly in his own office note
- Subsequently amended his own office note specifically to include the AMPnoPRO score
This is the Wrongful Denial Echo Chamber documented by the treating physician in writing: standardized, Medicare-approved assessment scores excluded on a procedural pretext manufactured by the corporate reviewer. Under Medicare LCD L33787 and Policy Article A52496, only one of three qualifying conditions was required for prosthetic replacement. Kissling met all three. UHC's reviewer knew this and denied anyway.
The Park
While using the inadequate learner prosthetic — the one UHC denied replacing — Kissling took his autistic daughter to a park. She became distressed and bolted toward the parking lot. He tried to run after her. The learner prosthetic failed. He nearly fell. He had to remove the prosthetic entirely. He could not reach her in time.
Another parent intervened and stopped her before she reached traffic.
Kissling has not taken his daughter outside alone since that day. UnitedHealthcare's denial removed his fundamental capacity to protect his child in an emergency. He has documented this in federal submissions. This is one of the damages in his case.
The Taxpayer Cost
The Wrongful Denial Echo Chamber does not save money. It transfers costs from the insurer onto taxpayers and onto the patient's body:
- A denied $55,000 stenting surgery triggered cascading wound failures over years
- 17 months of Apligraf delays allowed wounds to progress to bone-level infection
- The resulting amputation, revision surgeries, wound care, HBO therapy, prosthetics, and ongoing treatment costs: over $1.1 million in taxpayer-funded medical costs — and climbing
- Two university withdrawals: Kutztown University (3.92 GPA, Public Administration / paralegal) and Full Sail University (4.0 GPA, Course Director Award in Programming)
The $55,000 denial became $1.1 million in taxpayer costs. The insurer paid nothing. The patient paid with his limb. The public paid with their taxes.
What This Case Is Doing
In March 2026, Kissling submitted a formal briefing to the Senate Permanent Subcommittee on Investigations detailing the Prior Knowledge Omission mechanism as a documented, prosecutable fraud pattern — with a timestamped paper trail, physician corroboration, and an IRE-validated overturn as the evidentiary foundation.
The Clinical Integrity & Patient Safety Amendment — proposed as an addition to S.3829 — was drafted directly from this case. The Amendment's § 1 (Prohibition of Prior Knowledge Omission) names exactly what happened here. The § 5 Malpractice Trigger would have made the reviewing physician's refusal to acknowledge the K4 PT data a reportable act to the State Medical Board the moment Maximus overturned the denial.
Read the full PSI Briefing and Clinical Integrity Amendment in The Remedy Room →Ways We've Tried to Get the Message Out
Spreading awareness through media outreach is how this story has reached a wider audience — and how it continues to move.
Status Coup News Interview
This interview brought national attention to the human cost of insurance denials, reaching over 1.1 million viewers. Watch the full one-hour interview here.
Courthouse News Service Feature
This feature detailed the long battle with UnitedHealthcare, explaining how years of denied care for non-healing wounds ultimately and unnecessarily led to amputation.
Wall Street Journal Feature
The Wall Street Journal featured Michael Kissling and the mobile billboard campaign in its coverage of the national response to the UHC CEO shooting. On Mangione: "If he's Malcolm X, then I'm trying to emulate Martin Luther King."
Mobile Billboard Campaign
In partnership with People Over Profit, this mobile digital billboard took the stories of insurance denial directly to the streets, confronting corporate headquarters with the human cost of their policies. Learn more about the campaign here.
Criminal Justice Journalists — "As Mangione Faces Court for Killing, Many View Him as a Folk Hero"
This piece from Criminal Justice Journalists documented the broader public response to the Thompson killing — including the role of advocates like Kissling in channeling that anger toward legislative reform rather than further violence. Read the article → · Download PDF →
Primary Sources
Case IV — Active
Katelynn Kissling
Allentown, Pennsylvania · Highmark · Pennsylvania Act 146 Violation
This case is ongoing. The appeal and regulatory escalation documented here are active. This case is presented because it demonstrates the Clinical Integrity Amendment § 2 violation happening in real time — not as a closed record, but as a reason the law needs to change before more families have to write these letters.
The Story
Katelynn Kissling, 32, was prescribed Zepbound (tirzepatide) by Dr. Nicole Sully, DO — a board-certified physician specializing in bariatric medicine at LVPG Bariatric Medicine who treats adult patients exclusively for obesity and weight-related metabolic conditions. The medication was working. Dr. Sully's clinical notes documented it clearly: weight loss, neuropathy improving, sleep improving, metabolic markers moving in the right direction.
Highmark denied it. Then denied it again. Then again, with new reasons each time. The physician Highmark used to override Dr. Sully's recommendation was a pediatrician.
The Blood Work — It Was Working
Dr. Sully's records document measurable, objective metabolic improvement while Katelynn was on Zepbound:
While on Zepbound — October 2025
- Weight: 227 lbs (down from 243 lbs — 6.5% loss)
- Neuropathy: "Her neuropathy is feeling much better!!"
- Sleep: Improved to 7–8 hours restful sleep
- Dr. Sully's assessment: "Patient is making great progress!"
- HbA1c: Reduced from 5.5% toward 5.1% — moving away from prediabetes threshold
Five Weeks After Forced Cessation — November 2025
- Weight: 235 lbs — 8 pounds regained in one month, erasing half of all treatment progress
- "Her mood has been worse"
- "The pain in her legs/back has returned (this resolved when on Zepbound)"
- "Her hunger is intense and she is craving sweets"
- Forced onto Bupropion/Naltrexone — an inferior medication with known cardiovascular risks
This deterioration is not speculative. It is documented, measurable, and directly attributable to Highmark's denial. Every day the denial continues, the metabolic disease progresses and the risk of developing Type 2 Diabetes increases.
The Pediatrician Problem — § 2 in Real Life
Highmark's denial letter stated the reviewing physician was "a medical director who specializes in Pediatrics with special training and experience."
Katelynn is a 32-year-old adult woman. Zepbound is FDA-approved for chronic weight management in adults. Dr. Sully is a board-certified bariatric specialist who treats adult obesity patients daily. The reviewing physician is a pediatrician whose clinical practice centers on treating children.
Pennsylvania Act 146 — the state law that the Clinical Integrity Amendment codifies at the federal level — requires reviewing physicians to hold board certification in the same or directly relevant specialty as the treating physician. A pediatrician reviewing an adult bariatric medicine case does not meet this standard. If that pediatrician were to directly treat Katelynn for obesity, they would be practicing outside their scope of practice. Yet Highmark permitted them to override the specialist who is qualified to treat her.
"Would Highmark permit a pediatrician to override an oncologist's chemotherapy recommendations? A cardiologist's stent placement decision? Of course not. Yet they have done exactly that here."
— Michael & Katelynn Kissling, Formal Appeal to Highmark, December 9, 2025
The Moving Goalposts — Five Denials, Five Different Reasons
Initial denial — blank reason. No rationale provided. A procedural defect that alone warrants reversal.
Detailed physician denial — cites a 7.5% weight loss threshold and 6 months of documented lifestyle changes "prior to initiation." Katelynn had already achieved 6.5% weight loss — exceeding the evidence-based 5% clinical significance threshold. FDA does not require pre-treatment weight loss before prescribing Zepbound. Highmark's 7.5% threshold is not supported by any medical literature, clinical guideline, or peer-reviewed evidence. They have never provided a citation for it.
Saxenda denial — the "preferred alternative" Highmark steered her toward — using the identical arbitrary 7.5% threshold. The alternative pathway was an illusion.
False claim that internal appeals weren't exhausted — obstructing access to the Independent Review Entity.
New requirements never previously mentioned: OSA severity documentation, organ dysfunction evidence, dietary plans for continuation — despite the fact that all of this documentation had already been submitted, and despite the fact that Katelynn was already on the treatment when the denial began. Each time evidence is provided, Highmark shifts the rationale or adds new requirements.
The Arbitrary Threshold — Where Did 7.5% Come From?
Highmark's repeated denial rationale is that Katelynn failed to achieve 7.5% weight loss. She achieved 6.5% — losing 16 pounds from 243 lbs to 227 lbs. Highmark has never provided a single medical citation, clinical guideline, or peer-reviewed study supporting 7.5% as a meaningful threshold. Here is what the actual regulatory and medical record says:
FDA Drug Approval Standard
The FDA's guidance for approving obesity medications — both the 2007 guidance and the current draft guidance — requires that a drug demonstrate at least 5% decrease in body weight versus the control group after one year of treatment to be deemed effective. This is the federal standard the FDA itself uses to evaluate whether an anti-obesity medication works. Katelynn achieved 6.5% — 30% above the FDA's own efficacy threshold.
FDA Guidance: Obesity and Overweight — Developing Drugs and Biological Products for Weight Reduction →The FDA's Own Clinical Trial Endpoint for Zepbound
The SURMOUNT-1 phase 3 trial — the clinical trial on which the FDA based Zepbound's approval — used "weight reduction of 5% or more" as one of its two co-primary endpoints. In that trial, 85–91% of patients on Zepbound achieved ≥5% weight loss. The FDA approved the drug based on this threshold. Highmark's 7.5% threshold is more restrictive than the standard the FDA used to approve the medication they're denying.
HCPLive — FDA Approves Tirzepatide (Zepbound), SURMOUNT trial endpoints →Peer-Reviewed Medical Literature
Multiple peer-reviewed studies confirm the 5% threshold as clinically significant. A review published in Current Obesity Reports states: weight loss of ≥5% results in significant improvements in cardiometabolic risk factors — and this degree of weight loss is also required for the approval of novel anti-obesity medications by the FDA. The same threshold appears in the ACC/AHA/TOS and AACE/ACE clinical practice guidelines as the standard for evaluating treatment response.
Peer review: "What is clinically relevant weight loss?" — Taylor & Francis →Dr. Sully's Own Clinical Protocol
Katelynn's treating physician, Dr. Nicole Sully, documented in her October 3, 2025 treatment notes: "5–10% reduction in body weight is clinically significant and beneficial for overall health." This reflects the established medical consensus. The board-certified bariatric specialist treating the patient confirmed the evidence-based threshold. The pediatrician reviewing the case applied one that is 50% higher — without citation.
The bottom line: Highmark created a threshold — 7.5% — that is more restrictive than the FDA's drug approval standard, more restrictive than the clinical trial endpoints used to approve Zepbound, more restrictive than ACC/AHA/TOS and AACE/ACE clinical practice guidelines, and directly contradicted by the documented opinion of the treating specialist. They have never provided a citation for it. It is not a medical standard. It is an insurance-administrative standard invented to deny coverage of a medication the federal government has already determined is safe and effective — at a lower threshold than the one Highmark invented.
What This Case Means for the Amendment
The Clinical Integrity Amendment § 2 — the Act 146 Standard — was drafted in direct response to the UHC prosthetic denial documented in Case III. But the Highmark case proves the problem is not one insurer. It is not one drug. It is not one state. The mechanism is identical:
- A specialist physician recommends a treatment that is working
- An insurer assigns a reviewer outside that specialty to override the recommendation
- The patient deteriorates while the appeals process functions as a delay weapon
- The rationale shifts each time evidence is provided
Pennsylvania Act 146 already prohibits this. The Clinical Integrity Amendment would prohibit it federally. The case for the Amendment does not rest on one family's experience. It rests on the fact that two different families, two different insurers, two different states, and two different medical specialties produced the same documented mechanism — in the same household.
Case Status
Formal appeal submitted December 9, 2025. Case escalated to the Independent Review Entity, Pennsylvania Insurance Department, U.S. Department of Labor EBSA, and Patient Advocate Foundation. The complete appeal documentation — including Dr. Sully's clinical notes, the blood work timeline, and the full record of shifting denial rationales — has been submitted to regulatory bodies and is available to journalists, legislative staff, and legal counsel upon request.
The Broader Context
The structural analysis, public reaction, and systemic evidence behind why these individual cases are not outliers but expressions of a designed system.
UnitedHealth Group Is Too Big. Here's How That Puts Your Care at Risk.
UnitedHealth Group's vertical integration — owning insurance (UnitedHealthcare), PBMs (Optum Rx), physician groups (Optum Care), and technology platforms (Change Healthcare) — creates conflicts of interest at every step of care delivery that allow the company to prioritize profits over patients.
- UHG is the largest health insurer in the U.S. and the largest employer of physicians — Optum employs or is affiliated with ~90,000 doctors.
- The company's structure enables use of potentially flawed AI (like nH Predict) to deny necessary post-acute care, leveraging market power to squeeze out independent providers.
Opinion: A Grim Reminder of the Health Insurance Industry's Human Cost
Former Cigna executive and whistleblower Wendell Potter argues the murder of UHC CEO Brian Thompson exposed deep, simmering anger that millions of Americans feel toward a system rigged against them — and that this anger is predictable when companies "have acted with violence" toward patients through delays and denials that shorten lives.
Read the Press Herald Article → Watch CNN Coverage on YouTube →
Investors Call on UnitedHealth Group to Report on Public Health Costs of Care Denials
A coalition of shareholders — the Interfaith Center on Corporate Responsibility (ICCR), representing over 300 institutional investor groups — filed a formal proposal one month after the fatal shooting of UHC CEO Brian Thompson, stating that "public outrage over the exorbitant costs and restricted access to healthcare has reached a dangerous level."
Read the StatNews Article →UnitedHealth Is Sick of Everyone Complaining About Its Claim Denials
In the wake of CEO Brian Thompson's murder and subsequent public backlash, UnitedHealth began sending letters from defamation law firms to doctors who spoke out, arguing against shareholder proposals that would have required independent audits of denial rates and formal apologies to wrongly-denied families.
Read the Rolling Stone Article →Deny, Delay, Defend — A Whistleblower Speaks
A whistleblower called "Max," who worked for a third-party prior authorization company, reveals the "deny, delay, and defend" strategy is an "unspoken understanding." Management never said "deny more" — they said "send more requests to review," knowing patients would give up. An AMA survey found 80% of doctors report patients have abandoned treatment because of the prior authorization process, and 19% say prior authorizations have led to life-threatening events.
Watch More Perfect Union's Coverage →Hear Two UnitedHealthcare Representatives Discuss Someone's Health Insurance Case
A ProPublica investigation: Chris McNaughton, a college student with ulcerative colitis, sued UHC after the insurer denied his only effective medication as "not medically necessary." Through the lawsuit, he obtained an internal recording of two UHC employees laughing about the denial. A UHC doctor admitted under oath to signing over 10,000 denials, often without reviewing medical records.
Watch ProPublica's YouTube Coverage → Read ProPublica's Full Investigation →
The $1 Trillion Private Health Insurance Scam
Traditional public Medicare spends 98.6% of its budget on patient care. For-profit Medicare Advantage plans spend only 85% on care — 15% goes to administrative costs, executive salaries, and profits. Medicare Advantage costs taxpayers $300 to $1,000 more per patient than traditional Medicare. Americans are expected to pay nearly $1 trillion in overpayments to these private programs in coming years.
Watch More Perfect Union's Coverage →Bipartisan Support for Policies That Protect People from Medical Debt
84% of voters believe having health insurance should protect people from medical debt. 74% believe the current system is "mostly failing" at this. 35% of voters currently owe money from medical or dental expenses. The majority blame the insurance industry — not hospitals or drug makers.
Read the Survey Results →Letter to UnitedHealthcare on Retroactive Denial of Coverage for Emergency-Level Care
In June 2021, the American Hospital Association urged UHC to reverse a policy allowing retroactive denial of ER coverage for visits it deems non-emergent after the fact — warning of a "chilling effect" that would cause patients to avoid the ER. This policy came as UHG posted a 35% year-over-year jump in operating profits and $6.7 billion in Q1 2021 profit.
Read the AHA's Letter to Brian Thompson (2021) →UHC, Denials, and Wrongful Death — A Philosophical Inquiry
A philosophical analysis from a hospital denials manager: the distinction between claim denials (after treatment) and prior authorization denials (before treatment). Only the latter can plausibly constitute wrongful harm. The author notes that "the bad faith and deception of insurance companies are totally transparent" even at a low level — and that the prior authorization system specifically is where lives are at stake.
Read the Analysis →INHUMANE: UnitedHealth Group REJECTS 1 Out of 3 Medical Claims
UHC's high claim denial rate is presented as a deliberate strategy to starve doctor's offices of cash — forcing them into predatory loans to stay afloat, with UHC's own subsidiary Optum offering those loan services and directly profiting from the financial distress it creates. UHC denies 32% of all claims; the industry average is ~18%. UHC employs 70,000 doctors. 41% of healthcare providers have needed external loans to survive.
Watch Revolutionary Change's YouTube Coverage →Investors Are Pressing UnitedHealth Group to Deny More Care
Investors sued UnitedHealth Group — not for high denial rates, but because they believed the company's practices became "too consumer-friendly" under public pressure. This illustrates the core structural problem: the business model is built to deny. When a company is financially punished for improving patient outcomes, the system itself is the problem.
United Healthcare Insurance — a Scam Allowed to Happen
UHC denies approximately 33% of all claims — double the industry average. UnitedHealth Group reported a gross profit of approximately $90.1 billion for the twelve months ending September 30, 2024. The "nH Predict" AI algorithm has an alleged 90% error rate, yet continues to be used to deny care for elderly Medicare Advantage patients.
Read the USAttorneys.com Article →Trump DOJ Gives UnitedHealth a Green Light to Swallow Yet Another Competitor
The Trump administration's DOJ settled the Biden-era antitrust lawsuit that was filed to block UnitedHealth's $3.3 billion acquisition of home health provider Amedisys. Critics including Senator Elizabeth Warren called the settlement "half-baked," alleging it allows UHC to divest required locations to "similarly conflicted buyers" — suggesting the deal may be based on "political favors." UnitedHealth Group currently has approximately 2,700 subsidiaries.
Read the Common Dreams Article →