United Healthcare

[n8k]

Given the current litigation and press about United Healthcare and their propensity to delay and denial care, how can AARP continue to support this company?

[Winter2025VA]

[Sunday 4/6/25]

@n8k , it is all about $$$ and NOT about us!!! Glad you posted this. Take care, Nicole  👵

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[*** @n8k wrote 3/31/25:

Given the current litigation and press about United Healthcare and their propensity to delay and denial care, how can AARP continue to support this company? ***]

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[GailL1]

UPDATED 04/04/2025 - THE ON AGAIN / OFF AGAIN CYCLE CONTINUES

STAT 04/04/2025 - DOJ urges judge to move forward with Medicare Advantage fraud case against UnitedH... 

Previous post from 03/31/2025

This case has been resolved and UHC won the legal battle - unless the government wants to refill the case - it has been going on for a long time now so maybe they should just drop it and perhaps CMS could clarify their rules and procedures for these risk assessments.

KFF Health News 03/04/2025 - UnitedHealth Wins Ruling Over $2B in Alleged Medicare Advantage Overpay... 

The prior approval requirement is equivalent to other health insurance and is always included in managed care plans.  The provider knows how to submit the appeal to make sure that their medical protocols have been covered or they can do it and then follow the scientific documented way of treatments.   People should understand what it means to use a managed care plan - for Medicare or Medicaid.

IMO, traditional Medical should require more not less prior approvals - they already do some and now hopefully more will be added - this would save Medicare money and would help keep down Part B premiums and even rises in Medigap premiums if they did.   

[LG322302]

Good idea! So we can have more of this:

"During a breast reconstruction procedure, Dr. [Elizabeth] Potter [she is a surgeon in Texas] said she was contacted in the operating room and told that a UHC rep had called and needed to speak to her right away about the patient she was operating on. She scrubbed out and gave the "gentleman," a call — only to be questioned about the woman's diagnosis and "whether her inpatient stay should be justified."

"I was like, 'do you understand that she's asleep right now and she has breast cancer?'" Potter recounted. "And the gentleman said, 'actually, I don't — that's a different department that would know that information.'"

Clearly perturbed, Potter told the representative that the overnight post-surgery stay was indeed necessary — and that moreover, UHC should already have that information because the surgery had already been approved.

"'I need to go back,'" she recalled telling the man, "'and be with my patient now.'"

Exerpt from article on Futurism.com date Jan 9, 2025

[GailL1]

Yea, we will see how far it gets this time in the legal realm.  The problem is CMS could have controlled much of this similar to the rules they have for traditional Medicare but didn’t until just last year when some of the rules for prior approval were re-written by CMS.  However, it still seems that it will be another year or two before it is fully implemented.  Government moves slowly.

CMS.gov Newsroom 01/17/2024 - CMS Finalizes Rule to Expand Access to Health Information and Improve ... 

CMS.gov - [page last modified on 03/25/2025] - CMS Interoperability and Prior Authorization Final Ru...

This needs to be ironed out in the public area with all stakeholders having a seat at the table and then rules written where all concerned know what is expected of them - the insurers, the providers and the patients.

[n8k]

 The Illinois data shows UHC has a denial rate of 18% after appeals. MA denial rates for SNF are 20% while denial rates for traditional medicare are 3%. CalPERS is suing UHC for insider trading and fraudulently increasing risk scores. AARP should be ashamed!

Doctors detail profit-driven changes after UnitedHealth takeover | STAT

What United Healthcare Doesn’t Want You To Know

[GailL1]

Have you ever looked at the Medicare National Coverage Determination website?  

Many times this is the source of a prior approval.  The scientific bases of the treatment requested is outside of the protocols.  It is easy enough to fix with the doctor reviewing their files and or making sure their treatment codes meet the qualification needs.

I also read on the CMS site that only denials would be lower IF AN APPEAL IS ACTUALLY FILED -

KFF.org - Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2... 

from the link ~

Just 11.7% of denied prior authorization requests were appealed to Medicare Advantage insurers in 2023.

The majority of the 3.2 million denied prior authorization requests were not appealed, similar to previous years. In 2019, just 7.5% of all denials were appealed. That share increased somewhat in 2020 to 10.2% and was relatively stable in 2021 (10.6%) and 2022 (9.9%) (Figure 4). These include appeals of determinations that were both fully and partially denied.

Ever had an appeal of treatment under the traditional Medicare program?

CMS.gov- Levels of Appeal: Redetermination by a Medicare Contractor 

There are FIVE levels of Appeal - I can tell you that with working closely with the doctor and the insurer of a MA plan, it is even easier there.

The solution is clear - make BOTH coverages - traditional Medicare and Medicare Advantage insurers do the SAME thing in prior authorizations and appeals.