United Healthcare Investigation | Medicare Advantage Plan Fraud

United Healthcare is the nation’s largest provider of Medicare Advantage plans, with more than eight million customers, according to the Associated Press. These are privatized versions of the federal government program, mostly for people aged 65 and older.

The allegations United Healthcare include:

1. Claim Denials and Prior Authorization:

• High Denial Rates: UHC, like other large insurers, faces criticism for denying claims and requiring prior authorizations, leading to delays and difficulties in accessing necessary medical care.
• Algorithms and AI: UHC has been accused of using algorithms and AI-driven tools to deny claims, sometimes leading to wrongful denials.
• Retroactive Denials: UHC has been criticized for retroactively denying claims, leaving patients responsible for bills they thought were covered. 

2. Impact on Patients:

• Unexpected Bills: Claim denials and coverage disputes can leave patients with large, unexpected medical bills.
• Difficulty Accessing Care: Prior authorization requirements and network limitations can make it challenging for patients to see specialists or receive timely treatment.
• Stress and Anxiety: Dealing with claim denials and appeals can be a stressful and time-consuming process for patients. 

3. Provider Concerns:

• Contract Disputes: UHC has faced criticism for its contracting practices with healthcare providers, including disputes over reimbursement rates and network participation.
• Administrative Burden: Prior authorization requirements and claim denials can create administrative burdens for providers. 

4. Profit Motives and Corporate Practices:

• Prioritizing Profits: Critics argue that UHC, like other for-profit insurers, prioritizes profits over patient care.
• Anti-competitive Practices: UHC has been accused of engaging in anti-competitive practices that limit patient choice and increase costs.
• Lack of Transparency: Concerns have been raised about UHC’s lack of transparency in its claims processing and decision-making. 

5. Legal and Regulatory Scrutiny:

• Lawsuits and Investigations: UHC has faced lawsuits and investigations related to claim denials, billing practices, and the use of AI in healthcare.
• Government Oversight: Government agencies, like the Centers for Medicare & Medicaid Services (CMS), have scrutinized UHC’s practices. 

Understanding Traditional Medicare vs. Advantage Plans

Traditional Medicare is operated by the government. Most people receive Medicare Part A (hospital insurance) for free. Part B (medical insurance) typically costs $185 per month (may be higher depending upon your income), and covers 80% of your health care costs. To cover the remaining 20%, you must buy a Medigap or supplemental policy. Generally, they pay 80% of your health care costs. To cover the remaining 20%, you must buy a Medigap or supplemental policy. In general, most supplemental G plans (the most popular), cost between $100-$200/month. 

The good news: 

• Out-of-pocket costs. Are generally limited to the annual Part B deductible, which is $257 in 2025.
• Widest access to health providers. Only a small group of medical services require prior authorization.

The bad news:

• Premium for supplemental policy is more than for Advantage Plans
• You still have to buy a separate drug plan (Part D). In 2025 it is estimated to be approximately $46.50 per month.

Advantage Plans are operated by private insurance companies that contract with Medicare. They may offer additional benefits (dental, vision, hearing) that traditional Medicare does not cover. 

The good news:

Although you still must pay your monthly cost for traditional Medicare, ($185/month), the Advantage plan premiums are much lower, and sometimes, free. They usually include drug coverage (Part D) which is extra in Traditional Medicare.

The bad news:

• Limited provider networks: Typically enrollees must use doctors, hospitals, and other healthcare providers within a specific network.  Going out-of-network can mean higher costs or no coverage at all.
• Prior authorization: required for many services, which can delay or even prevent needed care.
• Travel limitations: May not offer coverage outside their service area.
• Higher costs: Although they may have lower premiums, they also have higher co-payment, deductibles, and out of pocket maximums (In 2025, the out-of-pocket maximum for Medicare Advantage is plans is $9,350 for in-network services. Some plans may have lower out-of-pocket limits, and those that allow out-of-network coverage may have a higher out-of-pocket maximum. For combined in-network and out-of-network services, the maximum can be up to $14,000 in 2025. 
• Denial of service: Some Medicare Advantage plans have been reported to delay or deny coverage for medically necessary care.

While Medicare Advantage plans may have lower premiums, they can also have higher copayments, deductibles, and out-of-pocket maximums, especially if you use out-of-network providers. 

The bottom line: Be careful what you wish for and read the fine print