ProPublica exposes UnitedHealthcare claim denials
- ProPublica’s investigation detailed how UnitedHealthcare sought to stop paying for Penn State student Christopher McNaughton’s ulcerative colitis treatment after it had stabilized him. - The reporting centered on a 2021 recorded call in which a United nurse and broker reacted after a reviewer deemed McNaughton’s treatment “not medically necessary.” - The case fits wider scrutiny of prior authorization, a process doctors say delays care and is often later reversed. (ama-assn.org)
ProPublica reported that UnitedHealthcare tried to cut off coverage for Christopher McNaughton, a Penn State student whose ulcerative colitis treatment was costing nearly $2 million a year. (propublica.org) McNaughton’s doctors said a Mayo Clinic specialist had assembled a drug regimen that finally brought his disease under control after years of severe symptoms, including arthritis, diarrhea, fatigue and blood clots. (propublica.org) ProPublica said United flagged him internally as a “high dollar account” while reviewing whether to keep paying for the treatment under the student health plan it provided at Penn State. (propublica.org) The story turned on a recorded May 2021 phone call. In it, nurse Victoria Kavanaugh told broker Dave Opperman that a doctor hired by United had found the treatment “not medically necessary,” and Opperman laughed before saying, “I knew that was coming.” (propublica.org) Prior authorization is the insurer’s checkpoint before it agrees to pay for a drug, scan or procedure. Claim files can include the notes, emails, recordings and reviews used to make that decision. (projects.propublica.org) ProPublica said McNaughton’s family sued and obtained internal emails, case records and recordings that exposed how the denial process worked inside the company. (propublica.org) United told ProPublica that it ultimately paid for all of McNaughton’s treatments and said its concern was his well-being, adding that his medication doses exceeded Food and Drug Administration guidelines. (propublica.org) The article landed into a larger fight over prior authorization across the insurance industry. ProPublica’s 2024 reporting found that EviCore, a contractor used by major insurers including UnitedHealthcare, handled reviews affecting more than 100 million people. (propublica.org) Doctors say these reviews often delay care. In the American Medical Association’s 2024 survey, 94% of physicians said prior authorization delays necessary treatment, and 82% said patients sometimes abandon care because of the process. (ama-assn.org) Appeals data shows denials are often not the last word. KFF’s analysis of Medicare Advantage data found insurers made about 50 million prior authorization determinations in 2023, denied 6.4% of requests, and overturned most appealed denials. (risehealth.org) McNaughton’s case gave ProPublica something patients rarely get: a recorded look at how a denial was discussed inside the company before the fight moved into appeals and court. (propublica.org)
