Heads up: this issue is from April 22, 2025. Because it covers time-sensitive coding and regulatory topics, some details may have changed since. See the latest issues for current guidance.
Assessing our focalPoint® data, Paul, Tracy, and I began to think something was wrong with United Healthcare payments when, for 2024, UHC had an in-office drug denial rate of 15.32%, and the average was around 10.75%. We believed then that this was due to the whole Change Healthcare outage. It has abated a bit this year and denials are down to 13.11%, but that is still too high. Additionally, practices have complained that United is taking way too long to pay their bills this year.
Not only were we seeing these issues, so were others. Check this out:
- Sen. Chuck Grassley (R-Iowa) has sent a letter to UnitedHealth Group CEO Andrew Witty demanding information on the company's Medicare Advantage billing practices.
- The Department of Justice has investigated UnitedHealthcare's medical billing practices that allegedly gave its Medicare Advantage plans additional payments. The new civil fraud investigation examines how the company records diagnoses that allegedly triggered the extra payments.
- A federal judge has dismissed five out of seven counts in a class action lawsuit against UnitedHealth Group but will allow it to continue. The suit claims that UHG, UnitedHealthcare, and NaviHealth denied claims by using an artificial intelligence program instead of medical professionals in Medicare Advantage plans.
- The Wall Street Journal was the first to report the news, citing conversations with multiple providers. UnitedHealth distributed advances to healthcare organizations, as they were unable to receive reimbursement when Change Healthcare’s network was shut down by ransomware. To date, it said 3.2 billion dollars have been repaid, but it's not clear if borrowers did so themselves. The providers said they have received threatening letters from UnitedHealth’s Optum wing, demanding payment on outstanding balances. According to the report, the insurer threatened to stop reimbursement payments until the advances were paid in full.
Based on all of the above, we decided to look at our drug database, focalPoint®, to compare United Healthcare Medicare Advantage versus other MA plans--CIGNA, CVS/AETNA, and Humana. Here are our findings:
- United Healthcare is the worst-performing Medicare Advantage payer when compared to CVS/AETNA, CIGNA, and Humana in these areas:
- Days from service to filing
- Days from service to payment (they were the worst for the 24 months in 2023-2024)
- Denial rate, as previously mentioned
- Denials increased steeply after the Change Healthcare outage. Particular problems include:
- Denial Reason Code 16, Lack of processing information, in these two Remark codes
- M119, Missing or Incorrect National Drug Code
- N822/N823 Missing Modifier (these apply to drug waste)
So, if you feel like United is your worst payer, you aren't wrong. If you have horror stories you'd like to share, please email me.
