UnitedHealth claims enrollees cannot challenge inappropriate care denials in court

Several months ago, Stat News exposed a common practice at UnitedHealth care and other big insurers: Large numbers of Medicare coverage denials through the use of AI. Bob Herman now reports for StatNews that UnitedHealth care claims a judge should dismiss a class action lawsuit against it because enrollees did not exhaust administrative remedies for appealing denials.

UnitedHealth is able to deny people coverage in Medicare Advantage with impunity and profit from its failure to comply with Medicare coverage rules. It knows that only a small fraction of people will appeal denials, so it can save money by not paying for care. It also knows that the Centers for Medicare and Medicaid Services, which oversees Medicare, does not have the resources to adequately oversee MA plans or the power to impose meaningful penalties on insurers when they violate their contracts and deny care inappropriately.

So UnitedHealth allegedly denied thousands of Medicare Advantage enrollees’ rehab therapy using an algorithm, without regard to the individual needs of its enrollees. And, now it’s claiming that their class action lawsuit against UnitedHealth for these denials should be dismissed because the vast majority did not exhaust their full appeal rights. (In addition, UnitedHealth claims that federal law protects insurers from these lawsuits; it argues that enrollees must sue the Department of Health and Human Services.)

UnitedHealth blames the federal government for their enrollees’ plight, a novel. If the appeals process were swifter, UnitedHealth claims, plaintiffs would not be suing.

The reality, of course, is that older vulnerable patients should not have to appeal inappropriate denials of necessary care; they should not face these denials. They wouldn’t have to if United considered their individual needs in making coverage determinations and put those above their shareholders’ needs. But, UnitedHealth’s shareholders’ needs appear to come first and that means Medicare Advantage enrollees might not get the Medicare benefits to which they are entitled.

We will know soon whether the judge in the lawsuit agrees with UnitedHealth that plaintiffs claims should be dismissed because they did not exhaust their administrative remedies. Plaintiffs say that had they done so, they would have suffered irreparable harm. They needed care quickly and couldn’t afford to pay for it out of pocket.

The government designed the Medicare Advantage program with a major payment system defect. It pays the insurers upfront to deliver Medicare benefits, and what the insurers don’t spend on care they largely get to keep. So, they have a powerful incentive to deny care inappropriately.

Here’s more from Just Care: