A Republican lawmaker has gone after UnitedHealthcare over its Medicare plan, calling the insurance company the "worst offender" in the industry.
North Carolina Republican Representative Greg Murphy on Fox Business on Monday discussed Republicans' efforts to reduce Medicare and Medicaid fraud, saying that UnitedHealthcare was "pushing" the boundaries of Medicare fraud. Newsweek spoke with experts about Murphy's comments.
Why It Matters
More than 32 million Americans were covered by Medicare Advantage plans last year, accounting for roughly half of the Medicare-eligible population.
UnitedHealthcare has received backlash in the months following the murder of CEO Brian Thompson in New York City. Since then, there's been an outpouring of anger towards the insurance industry based on claim denials.
House Republicans have also proposed a budget that would cut spending by $880 billion in the Energy and Commerce Committee, which oversees Medicare and Medicaid.
What To Know
Murphy said there's bipartisan support to reform Medicare based on the actions of insurance companies like UnitedHealthcare.
"I'll pick out the worst offender is United which is literally charging $1,000 more per enrollee than anyone else and they upcode them," Murphy said in an interview with Maria Bartiromo. "You take a stone-cold healthy person and they suddenly have 15 things wrong with them, then on the backside, they don't pay the people they should."
Murphy called this type of behavior by insurers a "scam."
"It's not necessarily fraud because some of this is legal but they're pushing the boundaries, and it's really immoral in fact," Murphy said.
"Medicare Advantage is highly popular with seniors due to the quality, access and affordability of care delivered and additional supplemental benefits—all while being more affordable for patients and reducing costs for the broader health system," a spokesperson for UnitedHealthcare told Newsweek.
Medicare Advantage is the privatized version of Medicare, and seniors often get extra benefits from the plans, including lower monthly premiums and extra vision and dental coverage.
However, some lawmakers and leaders in the healthcare industry have been critical of possible fraud by private insurers to charge the government for conditions patients do not actually have.
On average, Medicare Advantage members pay 45 percent less than those in Medicare Fee-for-Service (FFS) plans, saving approximately $2,500 in out-of-pocket costs, according to UnitedHealthcare.
And a 2024 Milliman analysis found that Medicare Advantage saves the federal government 4 percent compared to the FFS plans, making up $20 billion-plus in savings annually.
Special Master Suzanne Segal, who is an official appointed by a judge, recently recommended the dismissal of a more than decade-long challenge by the Department of Justice to UnitedHealthcare's Medicare Advantage business. Segal concluded there was no evidence to support the DOJ's claims that the company was overpaid.
A previous lawsuit alleged that UnitedHealthcare uses artificial intelligence (AI) to deny coverage to some elderly patients on Medicare Advantage despite allegedly being aware that the algorithm has a 90 percent error rate.
UnitedHealthcare also agreed to settle a different class action lawsuit for $2.5 million this year, affecting roughly 12,000 people.
The settlement attempted to resolve allegations that the company made unauthorized marketing calls that violated the Telephone Consumer Protection Act (TCPA).
What People Are Saying
UnitedHealthcare said in a press release on its website December 13: "UnitedHealthcare approves and pays about 90 percent of medical claims upon submission. Importantly, of those that require further review, around one-half of one percent are due to medical or clinical reasons. Highly inaccurate and grossly misleading information has been circulated about our company's treatment of insurance claims."
Chris Fong, a Medicare specialist and the CEO of Smile Insurance Group, told Newsweek: "The issue it seems is the adding of additional medical conditions on a member in order to increase the risk adjustment for that person and receive more money for their enrollment. The risk adjustment is designed to help compensate a plan for the higher cost a particular person will cost the plan in medical expenses which makes sense from a logical perspective. However, the risk of abuse is far too easy when conditions are not verified by a provider diagnosis."
Michael Ryan, a finance expert and the founder of MichaelRyanMoney.com, told Newsweek: "I don't see Rep. Murphy's comments as merely political rhetoric. To me they reflect real concerns about how companies like UHC are changing Medicare Advantage. Clear evidence suggests their practices show systematic attempts to maximize profit by minimizing care.
"The true measure of Medicare Advantage should be whether it delivers better outcomes for patients, not quarterly profits for insurers."
Alex Beene, a financial literacy instructor for the University of Tennessee at Martin, told Newsweek: "Medicare Advantage was sold to Americans as a marriage between Medicare and insurance companies that would ultimately be beneficial for recipients and provide better benefits and service. However, as Representative Murphy cites, the program has come to be more expensive for both the government and those who rely on its benefits, with companies like United Healthcare being called out for allegedly "upcharging" patients' bills."
What Happens Next
Members of Congress could become increasingly critical of private insurers and their Medicare Advantage programs and claims processes as the privatized version of Medicare continues to impact government spending.
"When the traditional Medicare program is the more financially responsible option for taxpayers' dollars and the needs of seniors, it's clear there's little 'Advantage' to this alternative, and members of Congress are catching on to this fact," Beene said.
Update 03/24/25 3:25 p.m. ET: This article has been updated to include additional information and a statement from United Healthcare.
