UnitedHealthcare limited a prior authorization rollback for home health and moved a federal fraud case toward dismissal. However a class action suit against them over AI-driven SNF denials advanced toward discovery. ▼
SNF operators should monitor how the HCSC-Cigna integration affects existing contracts and care coordination workflows during the transition period.
Healthcare Service Corp Buys Cigna Medicare Advantage Plans
For Cigna, this divestiture allows them to exit a turbulent Medicare market where they were a smaller player and focus on their core employer-sponsored coverage and Evernorth Health Services, which will continue to provide pharmacy benefits.
Meanwhile, HCSC significantly expands its footprint in the Medicare market, quadrupling its Medicare Advantage membership and broadening its national reach, which aligns with their mission to increase access to quality healthcare for older Americans.
Cigna to sell Medicare Advantage plans to Blue Cross Blue Shield insurer for $3.3 billion
— STAT. January 31, 2024Cigna closes $3 billion Medicare business sale to big Blue Cross Plan
— Forbes. March 19, 2025HCSC completes the acquisition of the Cigna Group’s Medicare and CareAllies businesses.
— Health Care Service Corporation. Marcy 19, 2025Cigna closes $3.7B sale of Medicare business to HCSC
— Healthcare Dive. March 20, 2025Cigna closes $3.3B sale of Medicare plans to HCSC
— Fierce Healthcare. March 19, 2025
Prior authorization requirement removed by UnitedHealthCare.
As part of their ongoing efforts to reduce prior authorization volume by 10%, UnitedHealthcare has just announced a change in their home health services requirements.
Beginning April 1, 2025, UHC will no longer require prior authorization or concurrent reviews for home health services managed by Home & Community (formerly naviHealth). This is the next step in an ongoing effort to modernize the authorization process and simplify health care for its members and providers.
— The Rowan Report, March 7, 2025
UnitedHealth Gets One Step Closer to Defeating High-profile Medicare Advantage Fraud Case.
UnitedHealth Group moved a step closer to ending a yearslong legal battle with the federal government that began with a whistleblower who alleged the company bilked billions of dollars through the Medicare Advantage program.
A special master assigned to the case by the judge issued a recommendation late Monday in favor of UnitedHealth, saying the Department of Justice was “lacking any evidence” to prove the company illegally withheld at least $2 billion in overpayments from taxpayers. The judge will use the recommendation to determine whether the case will proceed.
— STAT, March 4, 2025
UnitedHealth AI Denials Lawsuit: Medicare Advantage Coverage Disputes
A class action lawsuit was filed in November 2023 against UnitedHealth Group and a subsidiary alleging that they are illegally using an algorithm to deny rehabilitation care to seriously ill patients, even though the companies know the algorithm has a high error rate.
The case centers on UnitedHealth’s alleged disregard for older adults’ healthcare needs and highlights broader concerns about the use of AI in denying care within Medicare Advantage plans offered by various health insurance providers. The court has allowed the case to proceed with reduced claims, potentially reopening the discovery process to examine UnitedHealth’s AI practices.
Lawsuit against UnitedHealth over AI-Based denials of Post-Acute care moves ahead.
— Skilled Nursing News, February 14, 2025Class action suit over UnitedHealth’s AI care denials nears key moment. (paywalled)
— STAT. February 6, 2025UnitedHealth faces class action lawsuit over algorithmic care denials in Medicare Advantage plans. — — — (paywalled) STAT. December 12, 2023
✔ Comply with every payer's rules
✔ Equip your team with the Playbook
✔ Monitor rates and payer trends
