SUBSCRIBE TO OUR FREE NEWSLETTER
Daily news & progressive opinion—funded by the people, not the corporations—delivered straight to your inbox.
5
#000000
#FFFFFF
5
#000000
#FFFFFF
unitedhealthcare
Advocates Call for End of Deadly Tactic Used by For-Profit Health Insurers to Deny Treatment
The policy brief, published Monday by the American Economic Liberties Project (AELP), an anti-monopoly think tank, argues that the system is a massive drag on the US healthcare system, draining doctors of their time, fueling hiring shortages, and—most importantly—worsening treatable health problems for millions of Americans.
"This practice has massive financial and human costs, as I know personally from my family’s own tragic experience,” said the report's author, Hannah Garden-Monheit—a senior fellow at the AELP, whose late father was denied rehab by UnitedHealthcare after cancer forced his leg to be amputated.
"Prior authorization may have started as a narrow cost-control tool," she explained. "But it’s mushroomed into private insurers’ strategy for diverting resources from care toward their own profits. It’s time to ban prior authorization as we know it.”
The report examines how prior authorization went from a tool used sparingly to prevent payment for unnecessary treatments to what Garden-Monheit and co-author, AELP senior healthcare fellow Emma Freer, described as a "corporate care veto."
Around 1 in 5 adults with private insurance report that they or a family member had experienced a coverage denial in the past year, with 28% reporting that it worsened their health problem, according to a June survey from the Commonwealth Fund.
While insurers claim that their decisions to deny care are "evidence-based," the authors say that "in reality, the practice empowers distant corporate entities with a financial conflict of interest to override the professional judgment of physicians with firsthand knowledge of patients’ medical needs."
"There is generally little to no transparency or accountability for these decisions," the authors wrote.
While insurers claim that denials are reviewed by qualified clinicians, one survey from the American Medical Association (AMA) found that only 16% of physicians participating in peer-to-peer reviews reported that the “peer” was often or always qualified.
Garden-Monheit said United denied her father's claim multiple times, first citing his cancer diagnosis—the reason his leg was amputated in the first place—then by claiming that he had made significant enough "progress" that paying for rehab was unnecessary. The "progress" was that he "had figured out how to hop on one leg from his hospital bed to a chair."
Garden-Monheit describes how she, her father, and their care team were forced to navigate a "bureaucratic maze" by United, which ultimately led them to give up.
"At least twice, I learned of a denial only after calling United to check on the status of their request. They hadn’t even bothered with a letter," she said. "While the lines of communication felt frustratingly unpredictable, the answers always led to the same place: 'no.'"
As she explained in a recent op-ed for MS NOW: "My family’s experience wasn’t a one-off glitch. For United, the system was working as designed."
Former United chief medical officer Dr.Archelle Georgiou estimated that across just two Medicare Advantage plans from United and Humana, the companies save an estimated $100 million per year by denying claims that never get appealed. She said that's a "conservative estimate." Across the two plans, 1.75 million people were denied care, even after appeal.
While insurers pad their profits, patients suffer, the researchers found. Among people reporting a prior authorization denial, 41% said it delayed their care and 28% said their health problem worsened, according to the Commonwealth survey.
"My family’s experience wasn’t a one-off glitch. For United, the system was working as designed."
Meanwhile, the AMA survey found that 95% of physicians said that prior authorization delays care, 79% said it causes patients to abandon recommended treatments, and more than 1 in 4 doctors said it has caused a serious adverse event, including hospitalization, permanent impairment, or death.
Denied timely treatments, many patients end up paying for costly and ineffective alternatives that only make their situations worse and cause the costs to increase down the line.
"It was extremely difficult to obtain authorizations for substance abuse treatment when I covered the emergency department as a practicing psychologist," one healthcare professional, identified in the report as Nancy, said. "Other times, in my private practice, I would get authorizations and later experience ‘clawbacks’ where Blue Cross, for example, would decide the treatment was not medically necessary and take back the money already paid."
"It is impossible at times to provide sound ethical treatment and extremely hard to make a living," she said, "when reimbursement rates kept going down, and the insurance companies could take back the money they had already paid for no obvious reason.”
Prior authorization doesn't just deny care to patients. It also creates piles of paperwork for their doctors, taking away precious time that could be dedicated to their care.
The report found that physicians and their teams now spend so much on prior authorization paperwork that it consumes the equivalent of nearly 100,000 full-time physician and advanced practice clinician workloads, plus more than 213,000 clinic staff, costing as much as $32.7 billion each year. If prior authorization were eliminated, they found, it would free up enough capacity to turn a national physician shortage into a surplus.
(Graphic: American Economic Liberties Project)
A YouGov poll for AELP found that more than two-thirds of voters in both parties want legislation banning prior authorization outright. But the researchers said both the Trump and Biden administrations have enacted only minor reforms that "fail to address the structural conflict of interest that underpins the corporate care veto strategy."
Meanwhile, the industry is making the denial process even more ruthlessly efficient, increasingly deploying artificial intelligence to deny requests en masse.
According to a 2023 class action lawsuit, United's NaviHealth system used a predictive AI model to determine whether Medicare Advantage patients should receive rehabilitation care despite knowing that the model had a 90% error rate.
President Donald Trump, meanwhile, has expanded prior authorization for traditional Medicare through a pilot program that allows AI models to adjudicate claims in some states. In July, Senate Republicans blocked Democrats' attempt to end the pilot program.
As part of a national pro-AI strategy, Trump has also sought to preempt state laws banning the use of AI to deny care.
The AELP researchers called for a series of reforms to end prior authorization as it currently exists. Among other changes, they said decisions to authorize treatments should be made by independent third parties without the incentive to deny care, that denials must be evidence-based, that the use of AI tools to deny claims should be banned, and that physicians should review patients in person before denying their claims.
“For too long, prior authorization has allowed insurance companies to put profits ahead of patients by overruling doctors and delaying and denying essential care,” Freer said. “This status quo is failing patients, ratcheting up costs, and undermining the basis of effective, expert-informed care. It’s time to end this ‘corporate care veto’ and put medical decisions back where they belong: with patients and their doctors.”
Watchdog Exposes Millions in Medicare Advantage Lobbying Ahead of Dr. Oz Hearing
Health experts and others have sounded the alarm about Oz since Trump announceded his nomination in November, with many opponents highlighting the doctor's investments in companies with direct CMS interests and his push to expand Medicare Advantage when he unsuccessfully ran as a Republican to represent Pennsylvania in the U.S. Senate in 2022.
Medicare Advantage is a type of CMS-approved health insurance plan from a private company that seniors can choose for medical coverage instead of government-administered Medicare. Critics often call it a "profit-seeking healthcare scam."
Public Citizen's brief points out that last year, "more than half of all seniors eligible for Medicare were enrolled" in these private plans that "cost taxpayers hundreds of billions of dollars and deliver inferior care compared to traditional Medicare."
"Since their inception in 2003, Medicare Advantage plans are estimated to have cost taxpayers more than $600 billion in overpayments," the document notes. "These overpayments are expected to grow to $1 trillion over the next decade."
"Just seven companies account for 84% of all Medicare Advantage enrollment," the brief continues. "While lobbying disclosures do not reveal how much is spent on a single issue, disclosures reveal that these seven companies spent more than $330 million combined lobbying on all issues over the last five years, according to data from OpenSecrets."
Those companies are UnitedHealthcare, Humana, Blue Cross Blue Shield, CVS Health, Kaiser, Centene, and Cigna.
Public Citizen found that in 2024, they collectively had 328 lobbyists targeting the federal government, with nearly 70% of them specifically working on Medicare Advantage. Blue Cross had the most lobbyists focused on such plans (99), followed by Humana (33) and UnitedHealth Group (27).
"If Oz is confirmed as the CMS administrator, attacks on traditional Medicare are likely to move into overdrive," Eagan Kemp, a healthcare policy advocate at Public Citizen, warned in a Tuesday statement. "We should strengthen Medicare by improving it and expanding access to it, not weaken it through further privatization."
The Senate Committee on Finance is set to consider Oz on Friday morning. Since Trump returned to the White House in January, the GOP-controlled chamber hasn't blocked any of his nominees.
Suspect Still at Large After Shooting Oregon Insurance CEO's Home
The department said Wednesday that "the image below is believed to be the suspect, seen wearing all dark clothes with a possible hoodie or ski mask, and carrying a light-colored object in his hand. Police believe the suspect had a vehicle parked nearby."
Police in Lake Oswego, Oregon believe this is the suspect in a shooting at the home of SAIF CEO Chip Terhune on February 21, 2025. (Photo: Lake Oswego Police Department)
"Lake Oswego Police believe this was a targeted incident and do not believe there is an ongoing threat to the community," the department added. "Police are asking anyone with information about this incident to contact the Lake Oswego Police Detectives tip line at 503-635-0232. Tips can also be submitted anonymously through our website here."
Last week, the Oregon Journalism Project (OJP) obtained a message that Terhune reportedly shared with his neighbors about the incident. After thanking those "who spoke to the police when they knocked on your door so early," he explained that "at approximately 4 am, I awoke to what I initially thought were the sound of rocks being thrown at my windows."
"It became immediately apparent that no rocks were thrown but rather 3 bullets had been fired through my front door windows into my home," Terhune said. "[Name redacted] apparently reported to the police that she saw an individual dressed in black with a ski mask running away from my house and down the street."
OJP then reported Monday that it had obtained a weekend memo from Terhune to SAIF's more than 1,000 employees.
"We have received an email threat purporting to be from the person(s) responsible," Terhune wrote to staff on Saturday. "Although it does not target any specific employee, the email references knowledge of employee and relatives' names and addresses."
"Law enforcement is working diligently to investigate this matter and asked that we not share any additional specific information about the actual email," the CEO added.
According to KGW8, which got the memo from a SAIF employee, Terhune also said that the email contained many inaccuracies and the company would reach out to workers named in it to provide information about what was included about them.
Friday afternoon, on the other side of the country, in New York City, 26-year-old Mangione attended a procedural hearing.
"A group comprised mostly of women clad in green hats, shirts, and scarves has assembled outside the Manhattan Criminal Courthouse," The Cut reported. "They unfurl signs that say 'Health Care Is a Human Right' and 'Murder for Profit Is Terror'; a woman wearing a 'Cougars for Luigi' T-shirt holds up a banner that reads 'Luigi Before Fascists.'"
Despite an alleged manifesto that says in part, "These parasites simply had it coming," Mangione has pleaded not guilty to the murder as an act of terrorism and weapons charges in New York. He faces related cases in Pennsylvania and at the federal level.
Thompson's December 4 killing sparked a flood of commentary and debates about the nation's for-profit healthcare system.
In an interview shortly after the CEO was killed, U.S. Sen. Bernie Sanders (I-Vt.), a leading advocate of replacing the for-profit system with Medicare for All, said: "I condemn it wholeheartedly. It was a terrible act. But what it did show online is that many, many people are furious at the health insurance companies who make huge profits denying them and their families the healthcare that they desperately need."
Bolstering Sanders' point, December
polling shows that 69% of respondents put a "great deal or moderate amount" of blame for Thompson's death on health insurance companies' coverage denials, while 67% said insurers' exorbitant profits were to blame.
Most Popular