Senate Subcommittee Will Hold United Healthcare Group Accountable For Denied Coverage

December 9, 2024

According to Sen. Richard Blumenthal, (D-CT) chair of the U.S. Senate Permanent Subcommittee on Investigations, the increased prior authorization denials resulted in increased profit for the companies

Following reporting from ProPublica that indicated that insurance companies like CVS and UnitedHealthcare Group used the services of EviCore by Evernorth, owned by Cigna, which uses an artificial intelligence algorithm to deny coverage to policyholders, a Senate subcommittee is attempting to hold UnitedHealthcare Group accountable for denying Medicare Advantage claims.

According to the Minneapolis Star-Tribune, the shooting of UnitedHealthcare Group CEO Brian Thompson provided an avenue for more focus on the for-profit insurance company, which has resulted in people sharing stories online about their experiences of denials from the company.

The company, however, had already been under scrutiny from the government; in October, a Senate report was critical of three of the largest Medicare Advantage insurance companies, CVS, Humana, and UnitedHealthcare.

According to the report, between 2019 and 2022, the three companies denied prior authorization requests at an accelerated rate.

In 2022, UHC and CVS denied prior authorization requests at a rate three times that of their overall denial rates, while Humana’s prior authorization denial rate was over 16 times its overall denial rate.

According to Sen. Richard Blumenthal (D-CT), chair of the U.S. Senate Permanent Subcommittee on Investigations, increased prior authorization denials resulted in increased profit for the companies.

“Insurance companies say that prior authorization is meant to prevent unnecessary medical services. But the Permanent Subcommittee on Investigations has obtained new data and internal documents from the largest Medicare Advantage insurers that discredit these contentions,” Blumenthal said. “In fact, despite alarm and criticism in recent years about abuses and excesses, insurers have continued to deny care to vulnerable seniors—simply to make more money. Our Subcommittee even found evidence of insurers expanding this practice in recent years.”

ProPublica’s reporting depicts profit as the main goal for insurance companies and EviCore.

Even though Sen. Blumenthal doesn’t directly mention EviCore, the company promises a 3:1 return on investment to insurance companies, which its salespeople translate as a 15% increase in denials.

According to former employees of EviCore, the company’s algorithm, referred to as “the dial,” can be adjusted based on a desired outcome.

Dave Jones, a former California insurance commissioner, noted that while the practice of arbitrarily adjusting approval or denial is not a violation of standards, it does make him uncomfortable.

“That, to me, is troubling,” Jones said. “It suggests that the claim settlement procedure is not objective, right? It calls into question everything that’s occurring.”

Martin Lustick, a former insurance executive, told the outlet, “The fact that these big companies focused on profits and can play all these games is quite disturbing to me. They know the more reviews they do, the more denials they get.”

According to Will Humble, executive director for the Arizona Public Health Association, the greed of insurance companies needs to be regulated by Congress through reforming the Medical Loss Ration loophole, which currently incentivizes insurance companies to raise costs for policyholders.

“If insurance companies are not held accountable for their greed, our health care system outcomes will get worse. Across the country, patients can’t afford care, and hospitals can’t afford to keep the lights on and their doors open, while insurers rake in hundreds of billions of dollars,” Humble wrote in a 2023 op-ed for Arizona Mirror. “We need more regulation of health insurers to ensure that they are not putting profits before people.”

Humble continued, “Congress should step in and address this problem in order to lower the cost of health care and curb insurance industry abuses. We need Congress because we know that, left to their own devices, the big insurers have proven they will put profits ahead of people every single time.”

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