Health insurance industry ‘laying low’ in aftermath of UnitedHealthcare CEO shooting

The attack opened the floodgates for the public’s frustration over prior authorization and claim denials. Denials have been on the rise as the industry turns to technology to help make the process run more quickly.

On the way to a court hearing in Pennsylvania this week, Mangione appeared to call out the industry for being tone-deaf.

“It’s … an insult to the intelligence of the American people and their lived experience,” he said, according to several reports.

For years, the health industry has engaged in finger-pointing, with insurers and their lobbying groups blaming hospitals and drug companies for high prices, while the hospitals and drug companies redirect the blame to insurers.

Insurers remain convinced they are doing the right thing for the healthcare industry. The industry views prior authorization and claim denials as the only way to control costs and potential fraud in the health system.

If a doctor files a claim to authorize chemotherapy, for example, the insurer might deny it based on parameters set through artificial intelligence or a staff-managed system. Insurance companies may determine treatment is not appropriate or the cheapest first option and deny coverage until a doctor files the right code or selects a treatment within the company’s parameters.

This system has created frustration among doctors, who blame insurers for interfering in medical care and potentially disrupting a patient’s ability to get treatment. There have been examples over the years of insurers handling the denials callously to avoid having to pay out the claim. Only 0.2% of denied claims are appealed by patients.

In a leaked video, Andrew Witty, CEO of UnitedHealth Group, the parent company of UnitedHealthcare, said that the company will continue to defend its business practices.

“We guard against the pressures that exist for unsafe care or for unnecessary care to be delivered in a way that makes the whole system too complex and ultimately unsustainable,” Witty said in the video. “So we are going to continue to make that case, we are going to continue to do the work we do.”

The company also gave employees talking points to defend its work. Witty wrote a memo to employees asserting that daily operations are “done at the highest possible standard of quality.”

UnitedHealthcare has come under fire in recent years for its reliance on artificial intelligence to process claims. It has been deemed to have the highest claim denial rate at 32%, compared to the industry average of around 17%, according to Centers for Medicare and Medicaid data, which may not accurately reflect the general public but gives an idea of how each company manages denials.

UnitedHealthcare has about 14% of commercial insurance market share, followed by Elevance (ELV) at 12% and Aetna (CVS) at 11%, according to a study by the American Medical Association.

Some experts see an opportunity for sweeping changes.

“I’m optimistic in the industry’s potential to self-reflect and begin to think about changing how it interfaces with [patients],” SCAN Health Plan CEO Sachin Jain said. “Long term, it’s hard not to imagine all of us taking a look at how we deliver healthcare in this country.”

Some of those conversations are already happening in some companies in the aftermath of the shooting. But several insiders told Yahoo Finance that the industry is still shocked, and it will have to be an industrywide effort rather than one company making changes.

“You have an industry that is not very good at communicating and not very highly regarded,” one insider said. “When you throw this [shooting] on top of that, I do think it is a watershed event.”

Oscar Health CEO Mark Bertolini told Yahoo Finance that he understands the public’s frustration and that the shooting is a “wake-up call” for the industry. It’s why Bertolini, who leads a small insurer, believes that the antiquated system of employer-sponsored insurance set up after World War II needs to be changed.

But others think the sector is more in a wait-and-see mode, hoping the anger will subside.

“Logic never overcomes emotion,” a former health insurance executive said. “And for a period [of] time, this unleashed emotion, it will die down.”

Executives have openly said in the past that the system remains broken despite attempts over the years to fix it.

Part of the problem is that the healthcare system isn’t an equal field of cooperating market players; insurers, doctors, and others are engaging with each other using different degrees of technology and resources.

Previous attempts to control health costs have inspired the analogy that the industry is like a balloon.

“As policymakers push on spending growth in one area, those targeted [companies] can easily find other ways to increase their revenues,” wrote Elliott Fisher, a professor of health policy and medicine at the Dartmouth Institute and the Geisel School of Medicine.

Experts and insiders mused about the potential for lawmakers to take advantage of the situation and hold a hearing to challenge insurers on their claims denial practices and possibly pass new legislation to regulate the industry.

One insider who has served on healthcare company boards said, “I think some of the tactics have been particularly heinous, like using AI. It’s not very human. People have to admit there are predatory practices.”

SCAN’s Jain said the shooting called for a “broader reckoning for the industry.”

“We need to take a hard look at what we’re doing and how we do it,” Jain said.

Anjalee Khemlani is the senior health reporter at Yahoo Finance, covering all things pharma, insurance, care services, digital health, PBMs, and health policy and politics. That includes GLP-1s, of course. Follow Anjalee on social media platforms X (Twitter), LinkedIn Bluesky @AnjKhem.

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