Insurance Companies Use Shady Doctors to Deny Care, Investigation Finds

By Edward Lynn
Mid-America Publishing

In a New Orleans courtroom in April, federal appeals court judges questioned United Healthcare’s (UHC) denial of coverage for 15-year-old Emily Dwyer, whose anorexia was so severe that she had required residential treatment, for which she appeared wearing her 8 year old sister’s pants. But just 5 months later, doctors employed by UHC decided she didn’t need to continue the treatment, even though doctors who’d actually seen Dwyer considered it essential.

Judges on the 5th U.S. Circuit Court of Appeals weren’t convinced. Judge Andrew Oldham criticized this defense. “You’re only allowed to make decisions based on the facts,” Oldham said, lecturing lawyers for UHC in court, “you’re supposed to make decisions in the insured’s best interest.” And yet, Oldham lamented, UHC had dismissed Dwyer’s claims when “The record is teeming, teeming with concerning behaviors!” UHC’s approach, Oldham concluded, amounted to “we’ll just gamble with her life.”

Dwyer’s case is a focal point of a new investigation by ProPublica, which reviewed thousands of pages of court documents, insurance records, and interviews regarding insurer’s rejections of mental health claims. ProPublica’s reporting revealed that insurers often deny mental health coverage based on recommendations from a select group of psychiatrists who court proceedings have repeatedly shown to have, as ProPublica put it, “failed to meaningfully engage with patients’ families or medical providers or to adequately explain their decisions.”There are certain lists of doctors that are repeat players. We see them over and over,” Brian King, a Utah attorney who has repeatedly sued insurers over denials told ProPublica. “When we see those reviewers, it makes us more skeptical about whether a full and fair review has been provided.”

And, remarkably, a doctor’s decision to deny insurance coverage for a given treatment is not considered practicing medicine under the law, but rather simply advising the insurance company. Which protects the doctors from malpractice liability, even after showing a pattern of ill-considered denials of care.

 Indeed, multiple rulings reviewed by ProPublica have found that insurers ignored medical evidence, relied on “puzzling” and “dishonest” rationales, and used boilerplate language in denial letters. 

ProPublica’s reporting also showed a pattern of insurers shifting the justifications for denials of coverage when challenged, leaving families in prolonged legal battles, fighting one asserted basis for refusal after another.

Additionally, ProPublica found dozens of cases in which insurance companies violated federal laws mandating parity between mental and physical health coverage. But in a nation where health insurance is often tied to employment, officials at the U.S. Department of Labor told ProPublica they don’t have the budget or staff to properly police insurers, and Congress has failed to fund the agency’s repeated requests.

Dwyer’s case exemplifies these issues. Her family refinanced their home to keep her in treatment after UHC denied coverage. UHC’s decisions relied on psychiatrist Dr. Barbara Center, whose denial history includes errors and omissions highlighted in multiple lawsuits. In one case, Dr. Center’s  evaluation was riddled with factual inaccuracies, leading a federal court to describe her work as showing a “striking lack of care.” Despite this, insurers continue to hire her and similar doctors.

The Dwyers sued UHC in 2017, and in 2023, the 5th U.S. Circuit Court of Appeals ruled in their favor. The judges criticized UHC for ignoring medical evidence and using formulaic denial letters. Emily’s additional seven weeks in treatment proved critical to her recovery. Now 24, Emily credits the extended care with saving her life. She is a law student at Stanford, advocating for accountability in mental health insurance practices.

The reality of the situation for those seeking care, according to ProPublica’s findings, is that despite repeated court rulings that have highlighted systemic failures insurers face minimal consequences for dishonestly denying care. Consequently patients and their families facing financial ruin often settle cases to recover partial costs, giving insurers little reason to change their practices. And doctors who help insurance companies avoid financial responsibility for their customer’s treatments are shielded from malpractice suits. Leaving people without treatment they are insured for, again and again.

Read the full report at https://www.propublica.org/article/mental-health-insurance-denials-unitedhealthcare-cigna-doctors/.