Texas Attorney General Ken Paxton has opened an investigation into UnitedHealth Group, Inc. over allegations that the health insurance giant engaged in deceptive and unlawful practices that denied or delayed medically necessary care for Texas patients.
The investigation will examine reports involving UnitedHealth’s administration of health insurance benefits, coverage decisions, and prior-authorization practices. Paxton’s office said the allegations raise concerns under the Texas Deceptive Trade Practices Act and other state laws.
The attorney general’s office has issued Civil Investigative Demands to UnitedHealth seeking information and evidence related to the alleged practices.
Investigation Focuses on Coverage Decisions
According to the Texas Attorney General’s Office, reports indicate that UnitedHealth may have engaged in practices that interfered with patients’ access to medical treatment.
Among the allegations is that UnitedHealth bribed nursing homes to delay hospitalizing patients who required medical care. The investigation will seek to determine whether such conduct occurred and whether it violated Texas law.
The office also cited a case involving a Texas patient who received a letter from United approving a prior-authorization request for a procedure at RedBud Surgery Center in Austin. After the procedure was completed, United allegedly sent another letter withdrawing the approval, leaving the patient responsible for a substantial medical bill.
The attorney general’s office said the case raises questions about how United makes and communicates coverage determinations.
Paxton is also examining whether some of UnitedHealth’s coverage decisions could constitute the corporate practice of medicine. The concern centers on situations in which an insurer allegedly overrides a treating physician’s medical judgment by denying treatment the physician has determined is medically necessary.
The investigation has not established that UnitedHealth violated Texas law.
Paxton Criticizes Insurer Practices
Paxton said the allegations involving UnitedHealth have raised concerns about how the company treats Texas consumers.
“Alarming reports keep piling up about how United treats Texas consumers,” Paxton said in Monday’s announcement. “I will not tolerate any insurance company putting illegal corporate greed over the people of Texas.”
He said the investigation will seek evidence regarding the allegations and determine whether UnitedHealth violated state law.
“No Texan should be denied medically necessary care, dragged through endless appeals, or stuck with devastating bills after trusting their insurer’s word,” Paxton said.
TriWest Investigation Adds Broader Insurance Scrutiny
The UnitedHealth inquiry is part of a broader series of investigations by Paxton’s office involving alleged problems with health insurance claims and coverage decisions.
In a separate investigation, the attorney general is examining TriWest Healthcare Alliance Corp., which administers health care programs for military personnel, veterans, and their families under federal contracts, The Dallas Express reported last month.
The investigation followed complaints that TriWest improperly rejected claims after identifying patients as having other health insurance.
One case involved a Texas couple, the Shoemakers. Mr. Shoemaker, a military veteran receiving cancer treatment, allegedly had medical claims denied after TriWest classified his vision coverage as other health insurance.
The couple reportedly spent almost two years trying to correct the issue. The attorney general’s office said TriWest has acknowledged problems involving claims affected by other-health-insurance determinations.
Paxton’s office issued Civil Investigative Demands to TriWest and said investigators would speak with consumers and company employees.
That investigation, like the UnitedHealth inquiry, remains ongoing and does not establish that the company violated Texas law.
Blue Cross Investigation Examines Denials And Delays
Paxton’s office has also opened an investigation into Blue Cross and Blue Shield of Texas, Health Care Service Corporation and related entities, DX reported last week.
That inquiry centers on allegations that the insurer denied or delayed urgent medical care, including approval for the transfer of a newborn to a facility capable of providing urgently needed treatment.
The attorney general’s office alleged that administrative denials and potentially improper utilization reviews delayed approval for the transfer even though the applicable health plan covered the procedure.
Investigators are examining how the insurer reviews claims, communicates approval and denial decisions, and handles prior-authorization requirements. The inquiry will also consider whether claims are rejected without adequate review.
Paxton issued a Civil Investigative Demand seeking information to determine whether the companies violated Texas law, including the Texas Deceptive Trade Practices Act.
Blue Cross and Blue Shield of Texas explains that prior authorization allows an insurer and outside vendors to review whether requested services or medications meet medical-necessity and coverage requirements. The company also provides an appeals process for denied requests.
Multiple Investigations Target Insurance Practices
The investigations involving UnitedHealth, TriWest, and Blue Cross and Blue Shield of Texas address different allegations and insurance arrangements, but each involves questions about whether patients received benefits or medical services they were entitled to receive.
For UnitedHealth, the investigation is focused on alleged deceptive practices, prior-authorization decisions, coverage determinations, and the possibility that insurer decisions improperly interfere with physicians’ medical judgments.
The TriWest investigation involves alleged claim denials based on incorrect determinations that patients had other insurance, while the Blue Cross inquiry examines alleged delays and denials involving urgent care and prior authorization.
Civil Investigative Demands allow the attorney general’s office to obtain information as investigators determine whether alleged practices violated Texas law. The investigations themselves are not findings of liability, and the companies have not been determined to have violated the law based on the allegations announced by the attorney general.
Provided by Dallas Express
