On a late afternoon in November 2017, Witney Arch told her 1-1/2-year-old son to stop playing and come inside. Upset, he grabbed her right breast when she picked him up. She experienced a shock of pain but did not think it was anything serious. A week later, however, the ache had not subsided. After trips to several doctors, a biopsy revealed that Arch had early-stage breast cancer. Her surgeon told her that it was likely invasive and aggressive.
By the end of January, she had made two critical decisions. She would get a double mastectomy. And she wanted her operation at the Center for Restorative Breast Surgery in New Orleans, a medical facility renowned for its highly specialized approach to breast cancer care and reconstruction. The two surgeons who founded it had pioneered techniques that used a woman's own body tissue to form new breasts post mastectomy. The idea of a natural restoration appealed to Arch. "I don't judge anybody for getting implants, especially if you've had cancer," she said. "But I felt like I was taking something foreign out of my body, cancer, and I did not want to put something foreign back in."
Arch was a 42-year-old preschool teacher for her church, with four young children, living in a suburb of New Orleans. The 1-1/2-year-old had been born with Sturge-Weber syndrome, a rare neurological disorder. Caring for him consumed her life. By nature upbeat and optimistic, Arch felt blessed that her son's act of defiance had led to an early diagnosis. "We're going to pray about this and we're going to figure it out," she told her husband.
Arch asked her insurer, Blue Cross and Blue Shield of Louisiana, for approval to go to the center for her care, and the company granted it, a process known as prior authorization. Then, a week or so before her surgery, Arch was wrangling child care and meal plans when she got a call from the insurer. The representative on the line was trying to persuade her to have the surgery elsewhere. She urged Arch to seek a hospital that, unlike the center, was in network and charged less. "Do you realize how much this is going to cost?" Arch remembered the agent asking. Arch did not need more stress, but here it was — from her own health plan. "I feel very comfortable with my decision," she replied. "My doctor teaches other doctors around the world how to do this." Over the next year, Arch underwent five operations to rid herself of cancer and reconstruct her breasts.
Arch did not know it at the time, but her surgery would become evidence in a long-running legal fight between the breast center's founders, surgeons Frank DellaCroce and Scott Sullivan, and Blue Cross, Louisiana's biggest health insurance company, with an estimated two-thirds share of the market. DellaCroce and Sullivan had repeatedly sued the insurer, alleging that it granted approvals for surgery but then denied payments or paid only a fraction of patients' bills. They pointed to calls like the one Arch received as proof of the company's effort to drive away patients. The aggressive legal attack, they knew, was fraught. Litigation against the $3.4 billion company would take a long time and a lot of money. The chances of winning were slight. "You fight dragons at great peril," DellaCroce would tell friends. But this September, after 18 years and several defeats in court, jurors found Blue Cross liable for fraud. They awarded the center $421 million — one of the largest verdicts ever to a single medical practice outside of a class-action lawsuit. In a statement, Blue Cross said it "disagrees with the jury's decision, which we believe was wrong on the facts and the law. We have filed an appeal and expect to be successful."
Frustration with insurers is at an all-time high. The December fatal shooting of United Healthcare CEO Brian Thompson allegedly by Luigi Mangione serves as an extreme and tragic example. Doctors and insurers are locked into a perpetual conflict over health care costs, with patients caught in the middle. Doctors accuse insurance plans of blocking payments for health care treatments that can save the patients' lives. Insurance companies insist they shouldn't pay for procedures that they say are unnecessary or overpriced. It is easy to emerge from an examination of the American health care system with a cynicism that both sides are broken and corrupt.
However, interviews with scores of doctors, patients and insurance executives, as well as reviews of internal documents, regulatory filings and academic studies, reveal a fundamental truth: The two sides are not evenly matched. Insurance companies are players in the fight over money, and they are also the referees. Insurers produce their own guidelines to determine whether to pay claims. When a doctor appeals a denial, insurers make all the initial decisions. In legal settings, insurers are often given favorable standing in their ability to set what conditions they are required to cover. Federal and state insurance regulators lack the resources to pursue individual complaints against multibillion-dollar companies. Six major insurers, which include some of the nation's largest companies, cover half of all Americans. They are pitted against tens of thousands of doctors' practices and large hospital chains.
The Blue Cross trial provides a rare opportunity to expose in detail the ways that health insurance companies wield power over doctors and their patients. Blue Cross executives testified that the breast center charged too much money — sometimes more than $180,000 for an operation. The center, they said, deserved special attention because it had a history of questionable charges. But the insurer's defense went even further, to the very meaning of "prior authorization," which it had granted women like Arch to pursue surgery. The authorization, they said in court, recognized that a procedure was medically necessary, but it also contained a clause that it was "not a guarantee of payment." Blue Cross was not obliged to pay the center anything, top executives testified. "Let me be clear: The authorization never says we're going to pay you," said Steven Udvarhelyi, who was the CEO for the insurer from 2016 to 2024, in a deposition. "That's why there's a disclaimer.
From 2015 through 2023, the Baton Rouge-based insurer paid, on average, less than 9% of the charges billed by the breast center for more than 7,800 individual medical procedures — even though it had authorized all of them. Thousands of such claims were never paid at all, according to court records. Testimony revealed that the health plan never considered thousands of appeals filed by the center. Corporate documents showed Blue Cross executives had set up secret processes for approving operations and reimbursing the clinic and its doctors that resulted in reduced fees and payment delays. One lucrative strategy: A national-level policy allowed Blue Cross Louisiana to take a cut of any savings it achieved in paying the breast center on behalf of patients covered by out-of-state Blue Cross companies, meaning the less the insurer paid out, the more it earned.
In Sullivan's words, the insurer was hypocritical, "morally bankrupt." Blue Cross had stranded many of the center's patients with high bills, amounts that it had absorbed over the years. On several occasions, though, Blue Cross executives had signed special one-time deals with the center, known as single case agreements, to pay for their wives' cancer treatment. To Sullivan, it seemed the insurer was willing to pay the center when patients had connections but would fight when patients did not.
Blue Cross declined to comment on any individual cases but said in a statement that single case agreements were "common in the industry" and were available to all members when needed to access out-of-network providers.
Chapter 1
The Center
Nobody would take the breast center and its adjoining hospital as an ordinary medical establishment. The two facilities take up a city block along St. Charles Avenue, the thoroughfare famous for its streetcars, Mardi Gras parades and Queen Anne mansions. Patients access the complex — created by merging a former law office, funeral home, car dealership and Dunkin' Donuts — by driving around back where a porte cochere leads into a soaring atrium. Light pours in through windows set in the high ceiling. Arrangements of white orchids are scattered among comfortable couches and chairs. Here, women consult with doctors to plan their treatment. Surgeries are performed at the 39-bed hospital, which has an Icee machine in a family room. New-age music plays softly throughout the building. Rooms are designed to be as homey as possible, with medical gear hidden away and seascapes by a local artist hanging on the wall. One patient's husband referred to it as a "spa-spital."
The idea of combining the luxury feel of an upscale plastic surgery practice with the mission-driven zeal of a medical clinic came to DellaCroce and Sullivan while they were young surgeons. The two grew up in Louisiana. Sullivan spent much of his childhood in Mandeville, a suburb of New Orleans on the north side of Lake Ponchartrain, his dad employed in the oil and gas industry. His mother wanted him to be a priest or a doctor. "I definitely was not going to become a priest," he said. DellaCroce's father worked at the paper mill in West Monroe in the state's northern neck. His mother, a nurse, gave him an appreciation for medicine as a career that was "meaningful and challenging."
They became friends while working at the Louisiana State University medical center, where they earned the nickname "the Sushi Brothers" for their favorite lunch. They were drawn to microsurgery and breast reconstruction because it was an emerging field that was innovating and improving care. Both men became board-certified in plastic surgery. Sullivan, 60, is the hard-charging businessman, stocky, direct and blunt. DellaCroce, 58, with a ponytail, goatee and soft drawl, is more the diplomat, patient and cerebral. The pair have lectured around the world and written numerous medical journal articles.
They opened their first office in 2003 in a single room rented from a fellow doctor at what was then known as Memorial Medical Center, the hulking private hospital in New Orleans. They performed operations at facilities throughout the region but found that most gave little consideration to their patients' comfort. They wanted to build a different kind of hospital. "Can we give them that little bit of extra without breaking the budget to make the experience less awful? Can't make it great, but can you make it less awful?" DellaCroce explained. "Can you attend to the human side of this patient and give them the added value of peace and confidence?" Hurricane Katrina set back their construction plans, and the new edifice, named the St. Charles Surgical Hospital, did not open its doors until 2009. It boasts of being the only hospital in the country devoted solely to care for breast cancer patients who have received mastectomies. The center does not provide radiation or chemotherapy treatments. The majority of patients come from out of state.
Women seeking to have their breasts restored after a mastectomy face two paths. Some choose a relatively straightforward surgical procedure using implants filled with silicone or another gel. The center specializes in the other option, what's known as autologous tissue reconstruction, where a woman's own fat is taken from one part of the body, like the bottom or the stomach, and used to rebuild the breast. The procedure requires a longer recovery time, but the new breasts become part of the body.
The transplant surgery is lengthy and complex. Operations can last up to 12 hours with big medical teams involved. One surgeon performs the mastectomy while another creates a new breast by knitting together layers of fat and tissue. Concentration is intense. The surgeons stare through glasses with microscopes to connect new blood vessels with a needle that's thinner than an eyelash, using thread less than half the width of a human hair. DellaCroce and Sullivan invented techniques, for example, allowing tissue to be taken from multiple sites when a woman did not have enough fat in one part of her body for a full restoration.
One afternoon last fall, DellaCroce strode into a cavernous operating room to check on a patient. On the table in front of him, a woman lay covered in curtains of blue surgical cloth, only her torso exposed. Earlier in the day, a surgical oncologist had removed her right breast as part of a mastectomy to treat her cancer. Later, another surgeon had taken flaps of fat from her stomach and interlaced them with blood vessels to create a new breast to replace the lost one. Now, in the fifth hour of surgery, a physician's assistant leaned over her midsection, closing an incision along her side with some final stitches. Nurses hurried around the space, preparing to wrap up the operation. Paul Simon's "You Can Call Me Al" played in the background. The smell of burnt flesh hung in the air. A blue light signaled that the new arteries were successfully pumping blood. "Wow, that woman looks really good," DellaCroce told the physician's assistant. "Nice job."
There is no denying that the center's high-end treatment means high costs. The median charge for an operation and hospital stay is about $165,000. DellaCroce and Sullivan hired consultants to review other well-regarded practices, who advised them their prices were competitive with their peers. "We weren't asking to be paid LeBron James, best of the best, even though we feel we're in the top 1 or 2% of the country," Sullivan said. "We just wanted something fair."
Chapter 2
Blue Cross and Blue Shield
It is one of the quirks of the American health care system that insurers almost never pay the prices for procedures demanded by doctors and hospitals.
To understand why requires a tour of the grand bargain at the heart of the health insurance system. Insurance companies negotiate with hospitals and doctors to discount reimbursements on medical procedures, like office visits or MRI scans. Providers who sign these contracts are in network. Insurance companies like in-network doctors because they can budget for health expenses and set premiums accordingly. Doctors and hospitals agree to be in network because they get a steady stream of insured patients.
DellaCroce and Sullivan held contracts with insurers that resulted in average payments to the center's doctors in the $20,000 to $30,000 range. But DellaCroce and Sullivan never came to an agreement with Blue Cross. That made them an exception in Louisiana — the insurer is so dominant that 97% of local physicians and hospitals are in network. DellaCroce and Sullivan said the company was not offering them enough money — in some cases not even enough to cover the cost of the surgeries, they argued in court documents. The doctors and their hospital remained out of network, meaning they charged Blue Cross the full price for their procedures.
Such charges are controversial. Insurance companies and many health experts say they are too often inflated and untethered from actual costs. Physicians and hospitals say their fees are justified, reflecting the true price of medical care. In the end, insurers — especially in states like Louisiana, with few competitors — use their market power in negotiations to set reimbursements at what they want to pay, not what doctors charge.
At Blue Cross, Dwight Brower was charged with reviewing the bills from the breast center. He had worked as a physician at a small family practice in Baton Rouge and then at a local hospital before joining Blue Cross as a medical director. He helped oversee prior authorizations. While many patients assume that an approval means an insurer will pay for an operation, it is simply a recognition that a procedure is medically necessary. Federal law mandates that private insurers cover breast restorations for women who undergo mastectomies because of cancer or genetic risk. And patients, in general, are allowed to choose their own doctors.
However, since the center was out of network and had no contract with the insurer, Blue Cross determined how much it would pay for the treatment, and Brower believed that the breast center's bills were exorbitant. "I did not think that they were reasonable," he would later testify. Surgeons doing lung transplants or brain surgery rarely billed Blue Cross more than $50,000 for their work. Why should DellaCroce and Sullivan get so much more? "Don't get me wrong. The surgeons at the center are extremely skilled," he acknowledged. The operations were often lengthy. "But so are open-heart surgeries," he said. "Relative to some of the other extremely complicated surgeries done by other surgeons in other areas of the body, it just seemed like their fee schedule was extremely high."
Blue Cross Louisiana executives testified that they did not even consider doctors' invoices when making decisions on what to reimburse because such charges were "unregulated" and "nonstandard." Instead, they paid "an amount we establish" — unless the doctor's bill was cheaper. In the end, the insurer said it settled on reimbursing the breast center about the same as in-network doctors performing similar operations, even though DellaCroce and Sullivan did not benefit from having patients referred to them. In practice, that meant the insurer paid out a fraction of the breast center's bills. Of the 7,837 medical procedures in dispute in the lawsuit, involving 1,680 patients, Blue Cross paid about $43 million on invoices totaling $500 million. Some 60% of the claims weren't reimbursed at all. The difference between the bill and the payment could be striking. For example, in the case of Arch, Blue Cross paid $8,580 out of $102,722 for one operation. For another, it paid $3,190 out of $34,975.
Executives said the Blue Cross reimbursements were fair, designed to keep premiums low for the nearly 2 million Louisianans who depended on the insurer to cover their health care. Paying the breast center's full fees would add to its customers' burden, they said. "If we were to just agree to any rates or any prices set by physicians or any providers, it would cause cost to be exorbitantly high for both the plan and for members particularly, because we wouldn't be able to forecast or make sure those plans are actually sound," said Curtis Anders, the vice president of provider networks for Blue Cross. "Premiums would increase."
For many out-of-network doctors, payments lower than their invoices are an infuriating part of doing business. They absorb the costs, or pass them on to their patients, a practice known as balance billing that can result in medical debt. DellaCroce and Sullivan were the rare physicians with the tenacity to fight. The center collected money from both insurers and patients — but it carried the unpaid portion of invoices on its books. That amount grew every year as it battled Blue Cross.
DellaCroce and Sullivan were convinced that Blue Cross had singled them out for their obstreperousness, but they had no proof. Then, during a phone call one day, an employee for the center was talking to a Blue Cross representative to obtain a prior authorization. The representative let slip that the request required special handling. The breast center's doctors were flagged on an internal roster. It was called the targeted list.
Chapter 3
Discoveries
On Dec. 8, 2023, several dozen attorneys and paralegals from Chehardy Sherman Williams, one of New Orleans' top law firms, were celebrating their annual holiday party. They had gathered in a private dining room with gilded mirrors and shimmering chandeliers at Arnaud's restaurant, a bastion of Creole cuisine in the heart of the French Quarter. The waiters served shrimp remoulade, prime rib and turtle soup. Small talk filled the air.
Suddenly, several attorneys' cellphones buzzed as they all received the same email, a message from the lawyers for Blue Cross. It contained discovery for the case, more than 42,000 pages of internal documents, emails and policies. Matthew Sherman, one of the attorneys representing the center, turned to a colleague. "Can you believe this?" he asked. It was like something from a John Grisham novel, the kind of thing he and his friends had joked about at law school, a document dump at Christmas time. By long tradition, many of New Orleans' biggest law firms hold their holiday parties on the same Friday afternoon in December. Afterward, rival attorneys from around town gather for drinks under a flag of truce at a local bar. Sherman realized there would be no afterparty this year. Nor much of a holiday vacation.
The delivery of the documents was a Christmas gift nearly 20 years in the making. DellaCroce and Sullivan's first lawsuits against Blue Cross, involving 88 breach-of-contract claims filed in a Louisiana civil court beginning in 2006, were dismissed because of a federal court ruling regarding jurisdiction. A second lawsuit, which lasted from 2010 through 2017, resulted in limited discovery and a two-day trial in federal court. Jurors found that Blue Cross had failed to tell the center how much it would pay for procedures, but they also ruled the center had not been financially harmed. A judge dismissed the remaining claims.
DellaCroce and Sullivan launched their third lawsuit in February 2017 with a novel legal theory: They accused Blue Cross of fraud. They contended that for years the insurer had issued prior authorizations without the intention of paying the actual bills. Their lawyers had sought the targeted list during discovery to help prove the case. Blue Cross denied it existed.
But now, as Sherman and fellow attorney Patrick Follette began poring over the thousands of documents, they came upon a spreadsheet that said "Targeted Provider List." The first names on the list were DellaCroce and Sullivan. It was labeled "confidential" and dated June 2007 — about a year after the pair had filed their first lawsuit against Blue Cross alleging nonpayment. More digging turned up other documents. There was a "blocked" list that also featured the two doctors.
A corporate policy document provided what DellaCroce and Sullivan considered the most revealing explanation for Blue Cross' financial motivation. Blue Cross insurers are independent companies that operate under a common set of rules, similar to franchisees in a fast-food chain. When a person covered by Blue Cross in their home state receives treatment in another state, the Blue Cross where the treatment occurs pays the provider and then recoups the cost from the home-state plan. What the attorneys discovered was that Blue Cross Louisiana would receive a share of any savings it could generate for the home-state plan. Say, for instance, Blue Cross Alabama was facing a bill of $5,000 for a procedure. If Blue Cross Louisiana instead paid $1,000, it saved the Alabama plan $4,000. The policy allowed Blue Cross Louisiana to earn 16% of the savings — in this scenario, $640.
For DellaCroce and Sullivan, the revelations cemented their belief that Blue Cross was a bad corporate actor more interested in power and control than health care. The percentage fee incentivized the insurer to pay the doctors as little as possible. The bigger the savings, the more Blue Cross made. "It's win-win," DellaCroce said. "That's their pay day."
As the trial approached, Blue Cross attempted to settle the case. DellaCroce and Sullivan refused the offer as too low.
Chapter 4
The Trial
On the afternoon of Sept. 5, 2024, the case — St. Charles Surgical Hospital, L.L.C. and Center for Restorative Breast Surgery, L.L.C. v. Louisiana Health Service & Indemnity Company D/B/A Blue Cross/Blue Shield of Louisiana, Blue Cross & Blue Shield of Louisiana, Inc. and HMO Louisiana, Inc. — opened in Division C of the Orleans Parish Civil District Court, a high-ceilinged room with dark brown benches and tables, fake marble columns and fluorescent lights. James Williams, the chief litigator for the hospital, had already impressed the 45 potential jurors by memorizing all their names and backgrounds during jury selection. Now, he stood up and placed a football on the plaintiff's table in front of the 12 chosen to try the case, which included a third grade teacher, a movie stunt double and a hotel manager. He warned them that they would hear a lot of "insurance talk" from Blue Cross. "I'm going to ask you, ladies and gentlemen on the jury, keep your eye on the ball. Keep your eye on what this case is about," Williams told them. "If they start saying things like, ‘Well, oh, we paid them what we thought was fair, 9%,' keep your eye on the ball, right?"
Over 10 days — interrupted by a two-day break to allow a hurricane to pass across Louisiana — Williams made his case that Blue Cross had defrauded his clients by making promises to pay but failing to deliver.
Much of Blue Cross' defense had relied on the notice that a prior authorization was no guarantee of payment. The insurer had not committed fraud, it said, since it never explicitly promised the center to reimburse anything. Udvarhelyi, the former CEO, had insisted on that. But on the stand, Blue Cross witnesses provided a more nuanced explanation. They acknowledged that the disclaimer was not meant as a general excuse to free the company from paying bills. A prior authorization "usually" resulted in a payment, testified Brower, who reviewed the center's bills. He said that the notice was intended for specific situations. For instance, Blue Cross would not cover a woman who dropped out of her insurance before the operation. Nor would it pay anything if a patient had not met her deductible. But otherwise, Brower said, Blue Cross intended to compensate for a procedure that it had authorized. "It's inappropriate for us as a company to approve a code and then turn around and deny it," Brower said.
Over the years, the center had appealed thousands of reimbursements for being too low. It hired additional employees to manage the paperwork. At the trial, Blue Cross revealed that it had never considered any of the appeals — nor had it ever told the center that they were pointless. "An appeal is not available to review an underpayment," acknowledged Paula Shepherd, a Blue Cross executive vice president. The insurer simply issued an edict — the payment was correct.
This was the core of the case. The insurer set the rules. The insurer set the prices. Doctors could appeal to a state insurance regulator. But if that failed, and it often did, the only recourse was a long, costly lawsuit.
Williams summed up for the jury the center's treatment at the hands of Blue Cross: "Our payments are slow pay, low pay or no pay."
In countering those arguments, Blue Cross witnesses explained that the insurer was committed to paying for Louisianans' health care and keeping costs low. As a nonprofit, it directed any excess revenue from operations back into the business. (Udvarhelyi, the CEO, did acknowledge that his salary, over $1 million, included bonuses that depended on hitting revenue targets and increasing membership.)
Brian West, a Blue Cross executive who monitored payments, said the center had engaged in "egregious" billing practices. "They are bad actors in the billing world," he said. But company witnesses offered only a handful of examples. Sometimes the center mistakenly coded its bills in a way that appeared to charge for four separate breast reconstructions in a single operation. In other cases, the center asked for payment for two surgeons in the room at the same time. But Blue Cross, following Medicare guidelines, would pay two surgeons only 20% more than the reimbursement for a single surgeon.
Blue Cross did not accuse the center of any intentional miscoding — but the sloppy billing led to additional scrutiny, the company's witnesses said. The targeted list, a witness testified, had been created especially for the center, requiring all prior authorization requests to bypass normal routes for a special review by company doctors. The blocked list meant that each bill from the center received a manual scrub by payment specialists before reimbursement. Blue Cross acknowledged the careful checking often resulted in the need for more information from the center, which could result in slower processing of claims. But the lists, executives insisted, were not designed to reduce payments. "Basically, no harm was done," said Becky Juncker, who was involved in approving surgical procedures.
Company witnesses explained that the 16% received in saving money for out-of-state Blue Cross insurers was a fee to cover the costs of handling adjustments of the claim — though they were not able to explain why Blue Cross did not charge a flat fee for its services.
Blue Cross also defended itself against the accusation that it had paid nothing for 60% of the charges for individual procedures. Witnesses said the insurer had followed industry practice in bundling charges to make a single payment for an operation. An attorney for the center noted that it had never agreed to take bundled payments — Blue Cross had imposed them.
As to the calls to women like Arch? That was an effort to save members money. "Our medical area would reach out to our members who were utilizing out-of-network providers to help them understand the, I would say, the financial implications," said Shepherd, the Blue Cross executive vice president, in a deposition. "It could be financially catastrophic to a member to have an out-of-network claim that they are financially responsible for. It's a huge difference."
In summing up the case, Kim Boyle, the lead attorney for the company, told jurors that Blue Cross had not committed fraud. It had acted to ensure the company and its members paid a fair price for the center's services, she said. "There's no scheme. There's no plot. There's no mafia. There are no Blue Cross employees of Louisiana that are sitting in some smoke-filled room in Baton Rouge, plotting against these plaintiffs on St. Charles Avenue in New Orleans," Boyle said. "It's fiction; it's fancy; it's completely made up."
On Sept. 20, at 1:57 p.m., Judge Sidney H. Cates IV sent the jurors to deliberate. The center attorneys retreated to a nearby hotel to await the verdict. About two hours later, they were summoned back to Division C. Williams put his head down and swore. He worried that such a quick return in the legally complex case meant victory for Blue Cross.
The center's lawyers paid close attention to Cates as he reviewed the jurors' decision. It was a two-page form. If the jurors found in favor of Blue Cross, the judge would have no reason to read on. Cates flipped to the second page: The jurors had found Blue Cross liable for fraud. "Please express in dollars the total monetary compensation, if any, Blue Cross owes the hospital and the center for the damages," Cates said, reading from the verdict. "Net damages, $421,488,633." The center's lawyers stood and shook hands as the insurer's attorneys prepared to leave the courtroom.
DellaCroce was in surgery at the hospital, having expected a longer deliberation. Sullivan was in the courtroom to hear the verdict. Afterward, jurors approached and thanked him for his work. He teared up. "We would have given more if we had been asked for more. That's how egregious the fraud was," Juliet Laughlin, a 58-year-old property manager who served as forewoman, later said. "There had been wrong done."
Blue Cross has appealed the verdict. A health insurance trade group has warned that the finding sets a dangerous precedent. If allowed to stand, insurance companies in Louisiana may find themselves forced to pay whatever price is demanded by out-of-network doctors — which in turn could raise health insurance premiums across the state, the Louisiana Association of Health Plans said in a statement.
For DellaCroce and Sullivan, the verdict was vindication. They had refused to sign contracts they thought unfair. They had rejected settlement offers they thought too low. The trial had revealed Blue Cross' domineering behavior. "Fundamentally, I think their problem was that we were doctors who had control," DellaCroce said. "That was regarded as a threat."
In the months since the judgment, Blue Cross has not changed its practices, the doctors said. It has not approached with an offer that would bring the hospital in network. It still issues prior authorizations for women's surgeries. And it still pays only a fraction of the billed fees.
How We Reported the Story
This account is based on a review of thousands of pages of trial transcripts, depositions, federal and state court records, and internal corporate documents from Blue Cross and Blue Shield of Louisiana, the Center for Restorative Breast Surgery and the St. Charles Surgical Hospital; scores of interviews with doctors, patients and insurance executives; medical records; regulatory filings; and reports by academics, experts and the Louisiana state Senate. Some corporate documents discussed in court were placed under seal after the trial's conclusion. Blue Cross and Blue Shield of Louisiana was provided a detailed list of questions and responded with a written statement, cited in part in the story. The company declined to make any employees available for an interview. Former Blue Cross CEO Steven Udvarhelyi declined to comment, and former employee Dwight Brower did not respond to phone calls or emails.
Questions about whether oncologist Dr. Thomas Weiner would be permitted to continue practicing medicine intensified after a ProPublica investigation exposed a trail of patient harm tied to his practice.
In late 2020, St. Peter's Hospital in Helena, Montana, fired its oncologist, Dr. Thomas C. Weiner, and took the extraordinary step of publicly accusing him of hurting patients. The hospital said the doctor overprescribed narcotics and gave chemotherapy to patients who didn't have cancer, among other allegations.
Despite being notified by St. Peter's that it had revoked Weiner's privileges, the Montana Board of Medical Examiners renewed his license in 2021 and 2023. This week, the board renewed his license again for another two years.
Questions about whether Weiner would be permitted to continue practicing medicine intensified after a December ProPublica investigation exposed a trail of patient harm and at least 10 suspicious deaths tied to his practice. That investigation, which relied on thousands of pages of court records and dozens of interviews, detailed how Weiner built a high-volume business that billed as much as possible to public and private insurance while many of his patients received unnecessary, dangerous or substandard care.
While it's unclear what the medical board considered before renewing Weiner's license, the investigation published by ProPublica and Montana Free Press caught the attention of law enforcement. Criminal investigators with the Montana Department of Justice launched an official inquiry this month, according to three sources directly involved in the matter.
Weiner has denied mistreating his patients. He did not respond to a request for comment about his license being renewed and the Montana Department of Justice investigation.
After St. Peter's fired Weiner, he sued the hospital for wrongful termination and defamation. After a four-year legal battle, the Montana Supreme Court sided with the hospital in a ruling this month. The court wrote that the hospital's peer-review process leading to Weiner's dismissal was "reasonable and warranted due to the quantity and severity of Weiner's inappropriate patient care."
After it fired Weiner, the hospital inspected the files of more than 2,000 patients to whom he had prescribed controlled substances. Court records show that medical reviewers hired by St. Peter's highlighted the case of Sharon Dibble, a 75-year-old patient who died shortly after Weiner doubled her morphine prescription. That increase in morphine "led to respiratory arrest and the patient's demise," a medical expert hired by St. Peter's concluded.
Dibble's son, Tom Stevison, called the medical board's decision to renew Weiner's license "ridiculous."
"There's just too much evidence against him, pointing to wrongdoing, to recklessly relicense this guy," he said, referring to the hospital's allegations and ProPublica's reporting. "I do believe he should be held accountable."
Weiner previously denied the allegation that he overprescribed patients, including Dibble, and was critical of the medical review.
In the months after Weiner was fired, thousands of friends and former patients formed Facebook groups in support of him. They raised funds to rent a billboard in Helena that read, "WE STAND WITH DR. WEINER." On Tuesday, Dayna Schwartz, who led that effort, posted on Facebook, "Congrats Doc on your license renewal!!"
A spokesperson for the state Board of Medical Examiners referred a request for comment about Weiner's license renewal to its umbrella agency, the Montana Department of Labor and Industry. An agency spokesperson did not respond to questions before publication.
St. Peter's did not respond to requests for comment on the renewal of Weiner's license.
The medical board does not typically release information about current or past investigations unless it substantiates allegations of professional misconduct. If it does, a doctor's license can be suspended or revoked for many reasons, including billing fraud, unprofessional prescribing practices and failure to appropriately document patient care.
The criminal inquiry, led by the Montana Attorney General's Office, comes just months after the federal government settled with St. Peter's for making false claims when it billed government health programs for Weiner's services. The hospital agreed to pay back $10.8 million. The hospital has previously said it provides quality care and "this situation is isolated to a single, former physician, and we remain confident in the exceptional care provided by St. Peter's medical staff."
Federal prosecutors also sued Weiner, accusing him of an array of fraudulent practices, including billing federal insurance programs for unnecessary treatments or more expensive treatments than were delivered. Weiner has denied the allegations and, through attorneys, has moved to dismiss the case.
Pregnancy became far more dangerous in Texas after the state banned abortion in 2021, ProPublica found in a first-of-its-kind data analysis.
The rate of sepsis shot up more than 50% for women hospitalized when they lost their pregnancies in the second trimester, ProPublica found.
The surge in this life-threatening condition, caused by infection, was most pronounced for patients whose fetus may still have had a heartbeat when they arrived at the hospital.
ProPublica previously reported on two such cases in which miscarrying women in Texas died of sepsis after doctors delayed evacuating their uteruses. Doing so would have been considered an abortion.
The new reporting shows that, after the state banned abortion, dozens more pregnant and postpartum women died in Texas hospitals than had in pre-pandemic years, which ProPublica used as a baseline to avoid COVID-19-related distortions. As the maternal mortality rate dropped nationally, ProPublica found, it rose substantially in Texas.
ProPublica's analysis is the most detailed look yet at a rise in life-threatening complications for women losing a pregnancy after Texas banned abortion. It raises concerns that the same pattern may be occurring in more than a dozen other states with similar bans.
To chart the scope of pregnancy-related infections, ProPublica purchased and analyzed seven years of Texas' hospital discharge data.
When abortion was legal in Texas, the rate of sepsis for women hospitalized during second-trimester pregnancy loss was relatively steady.
Then the state's first abortion ban went into effect and the rate of sepsis spiked.
"This is exactly what we predicted would happen and exactly what we were afraid would happen," said Dr. Lorie Harper, a maternal-fetal medicine specialist in Austin.
She and a dozen other maternal health experts who reviewed ProPublica's findings say they add to the evidence that the state's abortion ban is leading to dangerous delays in care. Texas law threatens up to 99 years in prison for providing an abortion. Though the ban includes an exception for a "medical emergency," the definition of what constitutes an emergency has been subject to confusion and debate.
Many said the ban is the only explanation they could see for the sudden jump in sepsis cases.
The new analysis comes as Texas legislators consider amending the abortion ban in the wake of ProPublica's previous reporting, and as doctors, federal lawmakers and the state's largest newspaper have urged Texas officials to review pregnancy-related deaths from the first full years after the ban was enacted; the state maternal mortality review committee has, thus far, opted not to examine the death data for 2022 and 2023.
The standard of care for miscarrying patients in the second trimester is to offer to empty the uterus, according to leading medical organizations, which can lower the risk of contracting an infection and developing sepsis. If a patient's water breaks or her cervix opens, that risk rises with every passing hour.
Sepsis can lead to permanent kidney failure, brain damage and dangerous blood clotting. Nationally, it is one of the leading causes of deaths in hospitals.
While some Texas doctors have told ProPublica they regularly offer to empty the uterus in these cases, others say their hospitals don't allow them to do so until the fetal heartbeat stops or they can document a life-threatening complication.
Last year, ProPublica reported on the repercussions of these kinds of delays.
Forced to wait 40 hours as her dying fetus pressed against her cervix, Josseli Barnica risked a dangerous infection. Doctors didn't induce labor until her fetus no longer had a heartbeat.
Physicians waited, too, as Nevaeh Crain's organs failed. Before rushing the pregnant teenager to the operating room, they ran an extra test to confirm her fetus had expired.
Both women had hoped to carry their pregnancies to term, both suffered miscarriages and both died.
During Donald Trump's second presidency, ProPublica will focus on the areas most in need of scrutiny. Here are some of the issues our reporters will be watching — and how to get in touch with them securely.
"It's black and white in the law, but it's very vague when you're in the moment," said Dr. Tony Ogburn, an OB-GYN in San Antonio. When the fetus has a heartbeat, doctors can't simply follow the usual evidence-based guidelines, he said. Instead, there is a legal obligation to assess whether a woman's condition is dire enough to merit an abortion under a prosecutor's interpretation of the law.
Some prominent Texas Republicans who helped write and pass Texas' strict abortion bans have recently said that the law should be changed to protect women's lives — though it's unclear if proposed amendments will receive a public hearing during the current legislative session.
ProPublica's findings indicate that the law is getting in the way of providing abortions that can protect against life-threatening infections, said Dr. Sarah Prager, a professor of obstetrics and gynecology at the University of Washington.
"We have the ability to intervene before these patients get sick," she said. "This is evidence that we aren't doing that."
So ProPublica set out to do so, first by investigating preventable deaths, and now by using data to take a broader view, looking at what happened in Texas hospitals after the state banned abortion, in particular as women faced miscarriages.
"It is kind of mindblowing that even before the bans researchers barely looked into complications of pregnancy loss in hospitals," said perinatal epidemiologist Alison Gemmill, an expert on miscarriage at Johns Hopkins Bloomberg School of Public Health.
In consultation with Gemmill and more than a dozen other maternal health researchers and obstetricians, ProPublica built a framework for analyzing Texas hospital discharge data from 2017 to 2023, the most recent full year available. This billing data, kept by hospitals and collected by the state, catalogues what happens in every hospitalization. It is anonymized but remarkable in its granularity, including details such as gestational age, complications and procedures.
To study infections during pregnancy loss, ProPublica identified all hospitalizations that included miscarriages, terminations and births from the beginning of the second trimester up to 22 weeks' gestation, before fetal viability. Since first-trimester miscarriage is often managed in an outpatient setting, ProPublica did not include those cases in this analysis.
When looking at stays for second-trimester pregnancy loss, ProPublica found a relatively steady rate of sepsis before Texas made abortion a crime. In late 2021, the state made it a civil offense to end a pregnancy after a fetus developed cardiac activity, and in the summer of 2022, the state made it a felony to terminate any pregnancy, with few exceptions.
In 2021, 67 patients who lost a pregnancy in the second trimester were diagnosed with sepsis — as in the previous years, they accounted for about 3% of the hospitalizations.
In 2022, that number jumped to 90.
The following year, it climbed to 99.
ProPublica's analysis was conservative and likely missed some cases. It doesn't capture what happened to miscarrying patients who were turned away from emergency rooms or those like Barnica who were made to wait, then discharged home before they returned with sepsis.
Our analysis showed that patients who were admitted while their fetus was still believed to have a heartbeat were far more likely to develop sepsis.
Sepsis Rates Spiked for Patients Whose Initial Diagnosis Didn't Include Fetal Death
For patients in Texas hospitals who lost a pregnancy, about half were not diagnosed with fetal demise when they were admitted, meaning that their fetus may still have had a heartbeat at that time. Those patients saw a dramatic increase in sepsis after the state banned abortion.
"What this says to me is that once a fetal death is diagnosed, doctors can appropriately take care of someone to prevent sepsis, but if the fetus still has a heartbeat, then they aren't able to act and the risk for maternal sepsis goes way up," said Dr. Kristina Adams Waldorf, professor of obstetrics and gynecology at UW Medicine and an expert in pregnancy complications. "This is needlessly putting a woman's life in danger."
Studies indicate that waiting to evacuate the uterus increases rates of sepsis for patients whose water breaks before the fetus can survive outside the womb, a condition called previable premature rupture of membranes or PPROM. Because of the risk of infection, major medical organizations like the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists advise doctors to always offer abortions.
Researchers in Dallas and Houston examined cases of previable pregnancy complications at their local hospitals after the state ban. Both studies found that when women weren't able to end their pregnancies right away, they were significantly more likely to develop dangerous conditions than before the ban. The study of the University of Texas Health Science Center in Houston, not yet published, found that the rate of sepsis tripled after the ban.
Dr. Emily Fahl, a co-author of that study, recently urged professional societies and state medical boards to "explicitly clarify" that doctors need to recommend evacuating the uterus for patients with a PPROM diagnosis, even with no sign of infection, according to MedPage Today.
UTHealth Houston did not respond to several requests for comment.
ProPublica zoomed out beyond the second trimester to look at deaths of all women hospitalized in Texas while pregnant or up to six weeks postpartum. Deaths peaked amid the COVID-19 pandemic, and most patients who died then were diagnosed with the virus. But looking at the two years before the pandemic, 2018 and 2019, and the two most recent years of data, 2022 and 2023, there is a clear shift:
In the two earlier years, there were 79 maternal hospital deaths.
In the two most recent, there were 120.
Caitlin Myers, an economist at Middlebury College, said it's crucial to examine these deaths from different angles, as ProPublica has done. Data analyses help illuminate trends but can't reveal a patient's history or wishes, as a detailed medical chart might. Diving deep into individual cases can reveal the timeline of treatment and how doctors behave. "When you see them together, it tells a really compelling story that people are dying as a result of the abortion restrictions."
Texas has no plans to scrutinize those deaths. The chair of the maternal mortality review committee said the group is skipping data from 2022 and 2023 and picking up its analysis with 2024 to get a more "contemporary" view of deaths. She added that the decision had "absolutely no nefarious intent."
"The fact that Texas is not reviewing those years does a disservice to the 120 individuals you identified who died inpatient and were pregnant," said Dr. Jonas Swartz, an assistant professor of obstetrics and gynecology at Duke University. "And that is an underestimation of the number of people who died."
The committee is also prohibited by law from reviewing cases that include an abortion medication or procedure, which can also be used during miscarriages. In response to ProPublica's reporting, a Democratic state representative filed a bill to overturn that prohibition and order those cases to be examined.
Because not all maternal deaths take place in hospitals and the Texas hospital data did not include cause of death, ProPublica also looked at data compiled from death certificates by the Centers for Disease Control and Prevention.
It shows that the rate of maternal deaths in Texas rose 33% between 2019 and 2023 even as the national rate fell by 7.5%.
A New Imperative
Texas' abortion law is under review this legislative session. Even the party that championed it and the senator who authored it say they would consider a change.
"I do think we need to clarify any language," Patrick said, "so that doctors are not in fear of being penalized if they think the life of the mother is at risk."
State Sen. Bryan Hughes, who once argued that the abortion ban he wrote was "plenty clear," has since reversed course, saying he is working to propose language to amend the ban. Texas Gov. Greg Abbott told ProPublica, through a spokesperson, that he would "look forward to seeing any clarifying language in any proposed legislation from the Legislature."
Patrick, Hughes and Attorney General Ken Paxton did not respond to ProPublica's questions about what changes they would like to see made this session and did not comment on findings ProPublica shared.
In response to ProPublica's analysis, Abbott's office said in a statement that Texas law is clear and pointed to Texas health department data that shows 135 abortions have been performed since Roe was overturned without resulting in prosecution. The vast majority of the abortions were categorized as responses to an emergency but the data did not specify what kind. Only five were solely to "preserve [the] health of [the] woman."
At least seven bills related to repealing or creating new exceptions to the abortion laws have been introduced in Texas.
Doctors told ProPublica they would most like to see the bans overturned so all patients could receive standard care, including the option to terminate pregnancies for health considerations, regardless of whether it's an emergency. No list of exceptions can encompass every situation and risk a patient might face, obstetricians said.
"A list of exceptions is always going to exclude people," said Dallas OB-GYN Dr. Allison Gilbert.
It seems unlikely a Republican-controlled Legislature would overturn the ban. Gilbert and others are advocating to at least end criminal and civil penalties for doctors. Though no doctor has been prosecuted for violating the ban, the mere threat of criminal charges continues to obstruct care, she said.
In 2023, an amendment was passed that permitted physicians to intervene when patients are diagnosed with PPROM. But it is written in such a way that still exposes physicians to prosecution; it allows them to offer an "affirmative defense," like arguing self-defense when charged with murder.
"Anything that can reduce those severe penalties that have really chilled physicians in Texas would be helpful," Gilbert said. "I think it will mean that we save patients' lives."
Rep. Mihaela Plesa, a Democrat from outside Dallas who filed a bill to create new health exceptions, said that ProPublica's latest findings were "infuriating."
She is urging Republicans to bring the bills to a hearing for debate and discussion.
Last session, there were no public hearings, even as women have sued the state after being denied treatment for their pregnancy complications. This year, though some Republicans appeared open to change, others have gone a different direction.
One recently filed a bill that would allow the state to charge women who get an abortion with homicide, for which they could face the death penalty.
In January, standing before a cluster of television cameras on the steps of the state Capitol, Georgia Gov. Brian Kemp promoted his experiment in Medicaid reform as a showcase for fellow conservatives seeking to overhaul safety net benefits around the country.
"What we are doing is working," Kemp boasted about Georgia Pathways to Coverage. The federally subsidized health insurance program is supposed to cover nearly a quarter-million low-income Georgians who can prove they are working, studying or volunteering.
What the governor did not disclose, however, was that his program is not achieving two primary goals: enrolling people in health care and getting them to work, according to an examination by The Current and ProPublica. The findings were confirmed recently by an independent evaluation commissioned by the state that has yet to be publicly released.
As of the end of 2024, the Pathways program has cost federal and state taxpayers more than $86.9 million, three-quarters of which has gone to consultants, The Current and ProPublica found. The state asserted that costs increased because of a two-year delay to the program's launch.
A mere 6,500 participants have enrolled 18 months into the program, approximately 75% fewer than the state had estimated for Pathways' first year. Thousands of others never finished applying, according to the state's data, as reports of technical glitches mounted. The state also never hired enough people to help residents sign up or to verify that participants are actually working, as Georgia required, federal officials and state workers said.
As a result, the Kemp administration has quietly rolled back a core tenet it heralded when it launched Pathways as an alternative to government entitlement programs for poor people that many conservatives deride as handouts and the nanny state. Rather than verifying that people are working every month, Georgia is confirming that participants meet these requirements only at the time of enrollment and upon their annual renewal, the state said in January.
During Donald Trump's second presidency, ProPublica will focus on the areas most in need of scrutiny. Here are some of the issues our reporters will be watching — and how to get in touch with them securely.
Georgia's experience offers a warning for the nation as conservatives attempt to curtail federally subsidized health care for low-income Americans, as outlined by Project 2025, the playbook designed for a second Donald Trump presidency. Congressional Republicans are pushing for deep cuts to Medicaid along with requiring recipients to work. Right now, Georgia is the only state that imposes a work requirement for Medicaid coverage. But nearly a dozen largely Republican-led states are considering work requirements for Medicaid enrollees.
Federal and state officials who have worked on Pathways say a litany of bad decisions, some technical and some political, doomed the program from meeting Kemp's original goals. Even some lawmakers in Kemp's own party want to pull the plug on Pathways.
The quarter-million people eligible for Pathways would have had an easier road to coverage had the state simply chosen to expand Medicaid under the Affordable Care Act, the 2010 health reform law that extended insurance to tens of millions of Americans, said Joan Alker, executive director of the Center for Children and Families at Georgetown University McCourt School of Public Policy. Kemp is one of 10 Republican governors who refused federal government subsidies to expand Medicaid under the belief that entitlement programs encourage freeloaders and are a drag on federal and state budgets. Sixteen percent of working-age residents in Georgia lack health insurance, one of the highest uninsured rates in the nation.
In response to Pathways' low enrollment numbers, Kemp's spokesperson Garrison Douglas said the governor never thought it was realistic to enroll the entire pool of eligible Georgians in the program. Douglas said Kemp's health care strategy for low-income Georgians is superior to Medicaid expansion because it saves the state money and funnels participants into private health insurance, rather than what the Kemp administration has described as overregulated government-mandated plans that reimburse hospitals and doctors at lower rates.
"As the governor has said repeatedly, those who continue to promote full Medicaid expansion are selling Georgians a bill of goods," he said.
The Pathways program is slated to sunset this fall, but Georgia has filed a request with the Trump administration to extend the experiment for another five years with the less stringent verification rules, as independent evaluators recommended. The Trump administration did not respond to requests for comment about its support for Medicaid work requirements and its views on Georgia's Pathways experiment.
State officials did not explain why Georgia has not been able to meet its own verification standards.
"The governor's mandate for all state agencies is to continually seek ways to make government more efficient and accessible for hardworking Georgians," Fiona Roberts, a Department of Community Health spokesperson, said in a written statement.
The state requires Pathways participants to work at least 80 hours a month or be enrolled in school, job training or volunteering — activities the governor's office says it believes contribute to eventual "financial independence." Health policy research shows that requiring low-income people to work for health insurance does not increase coverage or boost their economic circumstances because most of them already have jobs.
"If the goal truly is to increase health insurance for low-income Georgians, they are doing it wrong," said Dr. Harry J. Heiman, a member of a state commission to study comprehensive health coverage and a professor at Georgia State University School of Public Health. "The one thing that Pathways seems to do well is waste taxpayer money on consultants and administrative costs."
Plagued by Tech Glitches
Pathways was supposed to help a group of Georgians whom the state had previously deemed ineligible for Medicaid: adults between 18 and 64 years old earning less than $15,650 a year if they are single, or $32,150 for a family of four.
The state told the federal government in its application to experiment with Pathways that it hoped to enroll 25,000 of the 246,000 Georgians eligible for Pathways during the program's first year.
But those seeking coverage faced technical hurdles right away, according to interviews with six applicants as well as federal officials and current and former state employees.
The enrollment portal crashed each of the three times Kelsey Williams tried to apply. The single mother had been kicked off Medicaid last spring, after her son turned 1, per state law allowing her to keep her coverage for a year after giving birth. She called the Pathways customer service hotline for help and was sent through a phone tree that ended in a voicemail asking callers to leave a message.
"You'd go from one robot voice to another," said Williams, who worked irregular hours as a convenience store clerk outside Macon.
No one called back. She gave up after nearly a month of trying. "I got the feeling that they really didn't want to help me," she said.
State officials have paid Deloitte Consulting more than $50 million so far for a software application that often froze and wiped out personal information, forcing applicants to start over. The technology also proved hard to navigate for many of Pathways' target clients who don't own smartphones or have access to reliable high-speed internet.
As of January, the state's own documents show that the program had a backlog of 16,000 applications awaiting processing, and in some months, upwards of 40% of people who started applications for Pathways gave up.
An independent evaluation from December, obtained by The Current and ProPublica, analyzed data gleaned from the first 13 months of the Pathways program and noted that applicants experienced administrative barriers to enrollment. People 50 and older had an especially difficult time proving they met the requirements, the evaluation said. The program requires applicants to provide paperwork that verifies their work status, including pay stubs and tax documents. That protocol contradicts Medicaid regulations that states should use available data to confirm most eligibility criteria, when possible, instead of making people provide documentation.
For Georgians who did manage to enroll, the technology problems persisted when they were required to verify each month that they had a job or were otherwise participating in a "qualifying activity."
Paul Mikell lives in an area outside Atlanta without reliable internet service — and he doesn't have the income for a phone plan with unlimited data. It takes him more than an hour each month to upload the employment documents necessary to reconfirm his eligibility, often using the free Wi-Fi at his public library.
Sometimes, Mikell said, the task has stretched days, even a whole week, because the Pathways verification portal freezes or crashes. One time, he said, he waited eight days for customer support to retrieve a password and restore his access.
The 49-year-old works part time for a hauling and trucking company in exchange for housing. He also picks up odd jobs to support his young son and elderly father. He does not receive traditional pay stubs that could be easily pulled by the state to verify his work status.
"It's really, really difficult," said Mikell, adding that stress over the possibility of losing coverage keeps him awake at night. "But it's the only health care for someone like me."
Mikell's informal employment situation is typical for many low-income Americans who exist outside mainstream financial networks, and illustrates why verification can be an arduous process for programs with work requirements, said Jennifer Wagner, an expert in Medicaid enrollment technology at the Center on Budget and Policy Priorities, a Washington think tank. In Georgia, 65% of people eligible for Pathways are employed at least part time, while many of the rest are tethered to unpaid work such as caregiving that Pathways does not recognize, state data shows.
To help automate the application and verification processes, Georgia uses digital tools to collect wage and work histories of employees at large companies as well as those who are self-employed. But these tools are not comprehensive, and the task of verifying applicants' eligibility for Pathways largely falls on a cadre of overburdened caseworkers.
In August 2023, a month after Pathways launched, the state was only able to verify that 39 of the 152 enrollees were indeed working or otherwise engaged in activities deemed acceptable by the state, according to state reports to the Centers for Medicare and Medicaid Services. Those reports attributed the low numbers to a lack of "functionality" and did not provide further explanation.
The state's contracts with Deloitte, which The Current and ProPublica obtained through a public records request, were heavily redacted and reveal no detail about the technical design of Pathways' digital platform or how it would be tested before launch.
Deloitte declined to comment and referred questions about the technical difficulties to Georgia officials. Roberts, the spokesperson for Georgia's Medicaid agency, referred to Pathways as "both a policy and technical success" but said it had to work through issues "consistent with the launch of a new program of similar scale and complexity."
"Based on feedback from customers and the community, the state continues to evolve the Pathways program and its processes," Roberts said in a written statement.
The state still requires Pathways recipients to upload paperwork every month, but Georgia is only verifying it annually, Roberts said. The state also says it is not kicking anyone off the rolls.
An Overwhelmed Workforce
Loosening Pathways' verification process does not change what federal and state officials say is another fundamental flaw in the program: Getting people enrolled would ultimately hinge on an understaffed department already struggling to keep up with processing applications for other safety net benefits.
About 30% of the staff at Georgia's Division of Family and Children Services that oversees benefits enrollment and employment verification had turned over between 2017 and 2022, according to state data. Former agency managers attribute the unusually high churn to a workforce fed up with low pay and high stress, exacerbated by the coronavirus pandemic.
In 2023, the year Pathways launched, the agency was already swamped.
Caseworkers had started the time-intensive task of reenrolling the 2 million Georgians who had traditional Medicaid benefits, a process that happens every five years to ensure that participants still meet the requirements.
Federal officials were simultaneously scrutinizing the department for its backlog of 157,000 food stamp applications and ordered it to develop a "corrective plan" to process those benefits more quickly. Georgia was also slipping behind the 45-day standard for processing Medicaid applications, according to federal data.
Meanwhile, for approximately six months before Pathways started, caseworkers needed extensive training for the new program, further delaying reviews of food stamps and Medicaid applications, former managers said.
That spring, Kemp approved a temporary fix to the department's workforce shortage: using federal grants to hire 300 additional caseworkers to handle the flood of Medicaid renewals. But state officials did not beef up staffing to handle Pathways applications, according to two federal employees and one former state manager, despite the fact that so much of Kemp's political capital was riding on the program's success.
The workload ballooned after Pathways' launch in July 2023, according to three former caseworkers. "I'd go into work every day with piles and piles of files, and each of those files represented a real human being with real suffering," said Deanna Matthews, who quit last year. "What people don't realize is that some of us were processing food stamp applications and our families were struggling and needing food assistance as well." (Starting salary for a caseworker who determines applicants' eligibility for federal benefits is approximately $32,000 — the same as the federal poverty line for a family of four.)
In December 2023, the state agency overseeing DFCS moved 200 caseworkers who had been processing applications for Medicaid to tackle the backlog of food stamp applications.
In Pathways' first six months, the department had enrolled just 2,300 people, according to state data.
In response to questions from The Current and ProPublica, Ellen Brown, a spokesperson for the Georgia Department of Human Services, said the state has committed enough people to administer Pathways but that it "can always use more caseworkers" and continues to hire.
At the state Capitol, Republican legislators representing rural counties, where large numbers of uninsured adults live, had begun questioning their governor's push for Pathways. They sought advice from other Republican-led states that were expanding Medicaid without work requirements.
Arkansas had removed its work requirements after a federal judge ruled that such policies resulted in a significant number of people losing health coverage, which goes against Medicaid's rules. The former head of North Carolina's Medicaid agency testified to Georgia lawmakers that Medicaid expansion would boost local economies, rather than drag down state budgets, as many conservatives fear.
Last spring, a bipartisan group of Georgia lawmakers introduced bills in both the House and Senate to allow Medicaid expansion and let Pathways sink into oblivion.
"What we're doing so far just hasn't seemed to work. And so, at some point, we've got to be open to more ideas," Georgia state Sen. Matt Brass, a Republican from Newnan and co-sponsor of the bill, said during a committee hearing at the time.
But the measure never made it to a full vote in either chamber.
Kemp quashed the rebellion after his allies in the Legislature argued that Pathways needed more time to prove itself. Georgia awarded Deloitte a $10.7 million advertising contract last summer to create television, radio and social media spots encouraging enrollment and to tout the program at community events around the state.
As a new legislative session is underway, no bill to abandon Pathways in favor of expanding Medicaid has emerged.
"We are focused on Pathways," said state Rep. Lee Hawkins, a Republican dentist who represents the rural constituency of Gainesville. "We are going to build on what we've got and focus on making it better."
The probe found widespread noncompliance and violations of federal law in how health plans and insurers cover mental health care, echoing the findings of a recent ProPublica investigation.
This article was published on Friday, January 24, 2025 in KFF Health News.
The U.S. Department of Labor found widespread noncompliance and violations of federal law in how health plans and insurers cover mental health care, findings that mirror a recent ProPublica investigation.
Health plans, and the companies that administer them, have excluded key behavioral treatments, such as therapies for substance use and autism, and offered inadequate networks of mental health providers, according to a 142-page report released Jan. 17 in conjunction with the Treasury and Health and Human Services departments.
The report, which the agencies are required to file regularly to Congress, also detailed the results of secret shopper surveys of more than 4,300 mental health providers listed in insurance directories and found an "alarming proportion" were "unresponsive or unreachable." Such error-ridden plans, commonly known as ghost networks, make it harder for patients to get the treatment they need, ProPublica has previously found.
Since 2021, the Labor Department has addressed violations in health plans that serve more than 7 million people, according to the report. The agency has worked to remedy the problems by seeking changes to plan provisions, policies and procedures, as well as working to ensure wrongly denied claims were paid.
But the report acknowledged that while plans and insurers have made some progress, they continue to fall short. For instance, federal officials wrote that insurers were working faster to fix problems in their plans once they had been identified, but officials had not seen sufficient improvement overall.
The report examined the enforcement and implementation of the federal Mental Health Parity and Addiction Equity Act, which requires health insurance plans to provide the same access to mental health care as they do to medical care. Last week, on the same day the report was released, department staff told ProPublica that the agency was investigating issues related to our reporting.
The Labor Department regulates insurance plans for about 136 million Americans who receive health coverage through their employers and is responsible for enforcing federal protections around their mental health claims. Federal regulators have struggled to hold insurance companies accountable for improperly denying mental health coverage, in part because of staffing and budgetary constraints.
The agency has asked Congress for additional funding on multiple occasions and, in its most recent congressional report, wrote that the agency is left with one investigator for every 13,900 plans it regulates, a higher workload than in previous years. Some temporary funding runs out in September, and its "full depletion will likely have catastrophic effects" on its enforcement capabilities, according to the report.
Timothy Hauser, a deputy assistant secretary of labor, said in an interview on the day of the report's release that the agency is investigating the oversight and management of doctors hired by insurance companies who repeatedly deny mental health coverage for patients — and may open additional investigations.
Hauser, who has worked at the agency for more than three decades and is staying on in the new administration, said the agency is probing how insurers use and supervise doctors they rely on to conduct reviews of coverage and whether those doctors review cases in a "fair and dispassionate" way. ProPublica's reporting raised serious concerns around those issues.
Last month, ProPublica examined how insurance companies, including UnitedHealth Group, Cigna, and Blue Cross and Blue Shield, rely on doctors to make crucial decisions on whether to approve mental health coverage even after courts have criticized their judgment. Judges have ruled that in denying such coverage, insurers violated federal law and acted in ways that were "puzzling," "disingenuous" and even "dishonest."
Some insurers and doctors, according to court records, engaged in "selective readings" of the medical evidence, "shut their eyes" to medical opinions that opposed their conclusions, and made critical errors in their reviews that were sometimes contradicted by medical records they had said they read.
Hauser said he could not comment on specific investigations but said that agency officials have discussed the ProPublica story, which he said "will have an impact on the questions we ask" and the "approaches we take."
At least one investigation in the past has resulted in the removal of a doctor and the outside review organization they worked for, a spokesperson for the Labor Department said previously.
Insurance companies across the country rely on doctors working on their behalf to determine whether the treatment sought by the patients' own doctors is medically necessary. If they determine it is not, they recommend denying coverage, which can leave patients in crisis and without the treatment they need. In some cases, those decisions have led to fatal consequences.
"It's supposed to be done with impartiality and without having been structured in such a way as to incentivize the physicians to favor denying claims as opposed to granting claims," Hauser said. "Similarly, the physicians and the providers should not be selected because of their propensity to to deny claims."
United, Cigna and Blue Cross and Blue Shield did not immediately respond to requests for comment but in the past have said they employ licensed physicians to conduct reviews and work to ensure the doctors issue appropriate coverage decisions. The companies have said they conduct regular audits of doctors' decisions, provide mentorship and coaching opportunities and are committed to providing access to safe, effective and quality care to patients.
Hauser said he was struck by the story of Emily Dwyer, who was featured in a ProPublica article that examined the role of company psychiatrists. She was 15 and suffered from severe anorexia — she arrived at a residential treatment center wearing her 8-year-old sister's jeans — when United Healthcare denied her coverage.
United argued that three separate doctors had reviewed her case. The Dwyers sued and lost, but appealed to the 5th U.S. Circuit Court of Appeals, which reversed that decision and ruled unanimously in favor of the family. In a harshly critical opinion, the judges wrote that the denial letters issued by the three doctors were "not supported by the underlying medical evidence." In fact, the court found, they were "contradicted by the record."
Dwyer, who was pleased to learn of the agency's investigation, said she hopes it results in "substantive action."
"I never would have thought that our story would be part of that," she said. "I think it's incredible that the Department of Labor is paying attention to this issue and is investigating the insurance doctors. But I also hope they look beyond the actions of the individual doctors to deeper issues of the way insurance companies operate more systematically."
Donald Trump's pick to lead the federal health agency has vowed to replace hundreds of staffers and shift research away from infectious diseases and vaccines. Such an overhaul could imperil the development of life-saving treatments, experts warn.
This article was published on Wednesday, January 15,2025 in ProPublica.
Lifesaving HIV treatments. Cures for hepatitis C. New tuberculosis regimens and a vaccine for RSV.
These and other major medical breakthroughs exist in large part thanks to a major division of the National Institutes of Health, the largest funder of biomedical research on the planet.
For decades, researchers with funding from the NIH's National Institute of Allergy and Infectious Diseases have labored quietly in red and blue states across the country, conducting experiments, developing treatments and running clinical trials. With its $6.5 billion budget, NIAID has played a vital role in discoveries that have kept the nation at the forefront of infectious disease research and saved millions of lives.
Then came the COVID-19 pandemic.
NIAID helped lead the federal response, and its director, Dr. Anthony Fauci, drew fire amid school closures nationwide and recommendations to wear face masks. Lawmakers were outraged to learn that the agency had funded an institute in China that had engaged in controversial research bioengineering viruses, and questioned whether there was sufficient oversight. Republicans in Congress have led numerous hearings and investigations into NIAID's work, flattened NIH's budget and proposed a total overhaul of the agency.
More recently, Robert F. Kennedy Jr., Trump's nominee to run the Department of Health and Human Services, which oversees the NIH, has said he wants to fire and replace 600 of the agency's 20,000 employees and shift research away from infectious diseases and vaccines, which are at the core of NIAID's mission to understand, treat and prevent infectious, immunologic and allergic diseases. He has said that half of NIH's budget should focus on "preventive, alternative and holistic approaches to health." He has a particular interest in improving diets.
Even the most staunch defenders of NIH agree the agency could benefit from reforms. Some would like to see fewer institutes, while others believe there should be term limits for directors. There are important debates over whether to fund and how to oversee controversial research methods, and concerns about the way the agency has handledtransparency. Scientists inside and outside of the institute agree that work needs to be done to restore public trust in the agency.
But experts and patient advocates worry that an overhaul or dismantling of NIAID without a clear understanding of the critical work performed there could imperil not only the development of future lifesaving treatments but also the nation's place at the helm of biomedical innovation.
"The importance of NIAID cannot be overstated," said Greg Millett, vice president and director of public policy at amfAR, a nonprofit dedicated to AIDS research and advocacy. "The amount of expertise, the research, the breakthroughs that have come out of NIAID — It's just incredible."
To understand how NIAID works and what's at stake with the new administration, ProPublica spoke with people who have worked for NIAID, received funding from it, or served on boards or panels that advise the institute.
Decisions, Decisions
The director of NIAID is appointed by the head of the NIH, who must be approved by the Senate. Directors have broad discretion to determine what research to fund and where to award grants, although traditionally those decisions are informed by recommendations from panels of outside experts.
Fauci led NIAID for nearly 40 years. He'd navigated controversy in the past, particularly in the early years of the HIV epidemic when community activists criticized him for initially excluding them from the research agenda. But in general until the pandemic, he enjoyed relatively solid bipartisan support for his work, which included a strong focus on vaccine research and development. After he retired in 2022, he was replaced by Dr. Jeanne Marrazzo, an HIV researcher who was formerly the director of the division of infectious diseases at the University of Alabama at Birmingham. She has spent much of her time in the halls of Congress working to restore bipartisan support for the institution.
NIH directors typically span presidential administrations. But Donald Trump has nominated Dr. Jay Bhattacharya to lead NIH, and current director Dr. Monica Bertagnolli told staff this week that she would resign on Jan. 17. A Stanford professor, Bhattacharya has spent his career studying health policy issues like the implementation of the Affordable Care Act and the efficacy of U.S. funding for HIV treatments internationally. He also researched the NIH, concluding that while the agency funds a lot of innovative or novel research, it should do even more.
In March 2020, Bhattacharya co-authored an opinion piece in The Wall Street Journal arguing that the death toll from the pandemic would likely be far lower than predicted and called for lockdown policies to be reevaluated. That October, he helped write a declaration that recommended lifting COVID-19 restrictions for those "at minimal risk of death" until herd immunity could be reached. In an interview with the libertarian magazine Reason in June, he said he believes the COVID-19 epidemic most likely originated from a lab accident in China and that he can't see Trump's Operation Warp Speed, which led to the development and distribution of COVID-19 vaccines at unprecedented speed, as a total success because it was part of the same research agenda.
Bhattacharya declined an interview request from ProPublica about his priorities for the agency. A recent Wall Street Journal article said he is considering how to link "academic freedom" on college campuses to NIH grants, though it's not clear how he would measure that or implement such a change. He's also raised the idea of term limits for directors and said the pandemic "was just a disaster for American science and public health policy," which is now in desperate need of reform.
Where the Money Goes
Grants from NIAID flow to nearly every state and more than half of the congressional districts across the country, supporting thousands of jobs nationwide. Last year, nearly $5 billion of NIAID's $6.5 billion budget went to U.S. organizations outside the institute, according to a ProPublica analysis of NIH's RePORT, an online database of its expenditures.
In 2024, Duke University in North Carolina and Washington University in Missouri were NIAID's largest grantees, receiving more than $190 and $173 million, respectively, to study, among other things, HIV, West Nile vaccines and biodefense.
Over the past five years, $10.6 billion, or about 40% of NIAID's budget to external U.S. institutions, went to states that voted for Trump in the 2024 presidential election, the analysis found. Research suggests that every dollar spent by NIH generates from $2.50 to $8 in economic activity.
That money is key to advancing medicine as well as careers in science. Most students and postdoctoral researchers rely on the funding and prestige of NIH grants to launch into the profession.
New Drugs and Global Influence
The NIH pays for most of the basic research globally into new drugs. The private sector relies on this public funding; researchers at Bentley University found that NIH money was behind every new pharmaceutical approved from 2010 through 2019.
That includes therapies for kids with RSV, COVID-19 vaccines and Ebola treatments, all of which have key patents based on NIAID-funded research.
Research from NIAID has also improved treatment for chronic diseases. New understandings of inflammation from NIAID-funded research has led to cutting-edge research into cures for Crohn's disease and ulcerative colitis, and a growing body of evidence shows how viruses can have long-term impacts, from multiple sclerosis to long COVID. When private companies turn that research into blockbuster drugs, the public benefits from new treatments, as well as jobs and economic growth.
The weight of NIAID's funding also allows it to play quieter roles that have been essential to advancing science and the United States' role in biomedicine, several people said.
The institute brings together scientists who are normally competitors to share findings and tackle big research questions. Having that neutral space is essential to pushing knowledge forward and ultimately spurring breakthroughs, said Matthew Rose of the Human Rights Campaign, who has served on multiple NIH advisory boards. "Academic bodies are very competitive with one another. Having NIH pull the grantees together is helpful to make sure they talk to one another and share research."
NIAID also funds researchers internationally, ensuring the U.S. continues to have an influential voice in global conversations about biosecurity.
Nancy Sullivan, a former senior investigator at NIAID, said that NIAID's power is its ability to invest in a broad understanding of human health. "It's the basic research that allows us to develop treatments," she said. "You never know which part of fundamental research is going to be the lynchpin for curing a disease or defining a disease so you know how to treat it," she said.
Sullivan should know: It was her work at NIAID that led four years ago to the first approved treatment for Ebola.
For years, it was a mystery: Seemingly out of the blue, therapists would feel like they'd tripped some invisible wire and become a target of UnitedHealth Group.
A company representative with the Orwellian title "care advocate" would call and grill them about why they'd seen a patient twice a week or weekly for six months.
In case after case, United would refuse to cover care, leaving patients to pay out-of-pocket or go without it. The severity of their issues seemed not to matter.
Around 2016, government officials began to pry open United's black box. They found that the nation's largest health insurance conglomerate had been using algorithms to identify providers it determined were giving too much therapy and patients it believed were receiving too much; then, the company scrutinized their cases and cut off reimbursements.
By the end of 2021, United's algorithm program had been deemed illegal in three states.
But that has not stopped the company from continuing to police mental healthcare with arbitrary thresholds and cost-driven targets, ProPublica found, after reviewing what is effectively the company's internal playbook for limiting and cutting therapy expenses. The insurer's strategies are still very much alive, putting countless patients at risk of losing mental healthcare.
Optum, its subsidiary that manages its mental health coverage, is taking aim at those who give or get "unwarranted" treatment, flagging patients who receive more than 30 sessions in eight months. The insurer estimates its "outlier management" strategy will contribute to savings of up to $52 million, according to company documents.
The company's ability to continue deploying its playbook lays bare a glaring flaw in the way American health insurance companies are overseen.
While the massive insurer — one of the 10 most profitable companies in the world — offers plans to people in every state, it answers to no single regulator.
The federal government oversees the biggest pool: most of the plans that employers sponsor for their workers.
States are responsible for plans that residents buy on the marketplace; they also regulate those funded by the government through Medicaid but run through private insurers.
In essence, more than 50 different state and federal regulatory entities each oversee a slice of United's vast network.
So when a California regulator cited United for its algorithm-driven practice in 2018, its corrective plan applied only to market plans based in California.
When Massachusetts' attorney general forced it to restrict the system in 2020 for one of the largest health plans there, the prosecutor's power ended at the state line.
And when New York's attorney general teamed up with the U.S. Department of Labor on one of the most expansive investigations in history of an insurer's efforts to limit mental healthcare coverage — one in which they scored a landmark, multimillion-dollar victory against United — none of it made an ounce of difference to the millions whose plans fell outside their purview.
It didn't matter that they were all scrutinizing the insurer for violating the same federal law, one that forbade companies from putting up barriers to mental health coverage that did not exist for physical health coverage.
For United's practices to be curbed, mental health advocates told ProPublica, every single jurisdiction in which it operates would have to successfully bring a case against it.
"It's like playing Whac-A-Mole all the time for regulators," said Lauren Finke, senior director of policy at the mental health advocacy group The Kennedy Forum. The regulatory patchwork benefits insurance companies, she said, "because they can just move their scrutinized practices to other products in different locations."
Now internal documents show that United, through its subsidiary Optum, is targeting plans in other jurisdictions, where its practices have not been curbed. The company is focused on reducing "overutilization" of services for patients covered through its privately contracted Medicaid plans that are overseen by states, according to the internal company records reviewed by ProPublica. These plans cover some of the nation's poorest and most vulnerable patients.
United administers Medicaid plans or benefits in about two dozen states, and for more than 6 million people, according to the most recent federal data from 2022. The division responsible for the company's Medicaid coverage took in $75 billion in revenue last year, a quarter of the total revenue of its health benefits business, UnitedHealthcare.
UnitedHealthcare told ProPublica that the company remains compliant with the terms of its settlement with the New York attorney general and federal regulators. Christine Hauser, a spokesperson for Optum Behavioral Health, said its process for managing healthcare claims is "an important part of making sure patients get access to safe, effective and affordable treatment." Its programs are compliant with federal laws and ensure "people receive the care they need," she said. One category of reviews is voluntary, she added; it allows providers to opt out and does not result in coverage denials.
ProPublica has spent months tracking the company's efforts to limit mental health costs, reviewing hundreds of pages of internal documents and court records, and interviewing dozens of current and former employees as well as scores of providers in the company's insurance networks.
One therapist in Virginia said she is reeling from the costly repercussions of her review by a care advocate. Another in Oklahoma said she faces ongoing pressure from United for seeing her high-risk patients twice a week.
"There's no real clinical rationale behind this," said Tim Clement, the vice president of federal government affairs at the nonprofit group Mental Health America. "This is pretty much a financial decision."
Former care advocates for the company told ProPublica the same as they described steamrolling providers to boost cost savings.
One said he felt like "a cog in the wheel of insurance greed."
Under ALERT
The year 2008 was supposed to mark a revolution in access to mental healthcare.
For decades, United and other insurers had been allowed to place hard caps on treatment, like the number of therapy sessions. But after Congress passed the Mental Health Parity and Addiction Equity Act, insurers could no longer set higher copays for behavioral services or more strictly limit how often patients could get them; insurers needed to offer the same access to mental healthcare as to physical care. The law applied to most plans, regardless of whether federal or state regulators enforced it.
As access to services increased, so did insurers' costs. Company documents show United was keenly aware of this threat to its bottom line.
But there was a loophole: Insurers could still determine what care was medically necessary and appropriate.
Called ALERT, the algorithmic system was created years earlier to identify patients at risk of suicide or substance use. The company redeployed it to identify therapy overuse.
Company and court filings reveal that ALERT comprised a suite of algorithms — totaling more than 50 at one point — that analyzed clinical and claims data to catch what it considered unusual mental health treatment patterns, flagging up to 15% of the patients receiving outpatient care.
The algorithms could be triggered when care met the company's definition of overly frequent, such as when patients had therapy sessions twice a week for six weeks or more than 20 sessions in six months. Therapists drew scrutiny if they provided services for more than eight hours a day, used the same diagnosis code with most clients or worked on weekends or holidays — even though such work is often necessary with patients in crisis.
The system was originally designed to save lives, said Ed Jones, who co-developed the algorithm program when he worked as an executive at PacifiCare Behavioral Health, which later merged with United. Using ALERT to limit or deny care was "perverting a process that was really pretty good," he told ProPublica.
Once patients or therapists were flagged, care advocates, who were licensed practitioners, would "alert" providers, using intervention scripts to assess whether care was medically necessary. The calls felt like interrogations, therapists told ProPublica, with the predetermined conclusion that their therapy was unnecessary or excessive.
ProPublica spoke with seven former employees from Optum who worked with the ALERT system from 2006 through 2021. They requested not to be named in order to speak freely, some citing fears of retaliation.
Even though the reviews were purportedly intended to identify cases where care was inappropriate or violated clinical standards, several former care advocates said these instances were rare. Instead, they questioned care if it passed an allotted number of sessions.
"It had to be really extreme to help the client be able to continue with the care," said one former care advocate, who was troubled by the practice. "Not everyone with depression is going to be suicidal, but they still need therapy to support them."
The advocates often overruled a provider's expertise, a former team manager said. "There was always this feeling, ‘Why are we telling clinicians what to do?'" he said. "I didn't think it was OK that we were making decisions like that for people."
If the advocates found fault with therapists' explanations — or couldn't persuade them to cut back on care — they elevated the case to a peer-to-peer review, where a psychologist could decide to stop covering treatment.
According to court records, regulators alleged United doled out bonuses to care advocates based on productivity, such as the number of cases handled, and pushed workers to reduce care by modifying a therapist's treatment or referring therapists to peer review in 20% of assigned cases.
At one point, care advocates were referring 40%, regulators alleged in court filings. Each peer review tended to last less than 12 minutes, offering providers little time to prove they had a "clear and compelling" reason to continue treatment.
Former advocates described feeling like parts of a machine that couldn't stop churning. "Literally, we had to tell the company when we were going to the restroom," one advocate said, "and so you would do that and come back and your manager would say, ‘Well, that was a little long.'"
The former workers told ProPublica they were pressured to keep calls brief; the rush added to the tension as therapists pushed back in anger.
"There was an expiration date on those jobs because there was such a pull on you emotionally," one former care advocate said.
Three of them quit, they told ProPublica, citing damage to their own mental health.
All concluded that while United may not have set official caps on coverage, it had done so in practice by limiting mental health services more stringently than medical care. Therefore, it was breaking the federal parity law.
While California and Massachusetts got United to scale back its use of ALERT within their jurisdictions, New York was able to stretch its reach by teaming up with the U.S. Department of Labor to investigate and sue the insurer. Together, they found that from 2013 through 2020, United had denied claims for more than 34,000 therapy sessions in New York alone, amounting to $8 million in denied care.
By using ALERT to ration care, United calculated that it saved the company about $330 per member each time the program was used, the regulators said in court records. Cut off from therapy, some patients were hospitalized. The regulators did not specifically address in court filings whether the treatment denials met medical guidelines.
The company, which denied the allegations and did not have to admit liability or wrongdoing, agreed to pay more than $4 million in restitution and penalties in 2021. Notably, it also agreed to not use ALERT to limit or deny care.
The final terms of the settlement, however, only applied to plans under New York and federal regulators' jurisdiction.
Rebranded Reviews
ProPublica has reviewed documents behind Optum's ALERT and Outpatient Care Engagement programs. Credit: Obtained by ProPublica
In the three years since the settlement, the company has quietly rebranded ALERT.
The Outpatient Care Engagement program continues to use claims and clinical data to identify patients with "higher-than-average intensity and/or frequency of services," according to internal company documents, to ensure "that members are receiving the right level of care at the right time."
Up to 10% of cases are flagged for scrutiny, public company documents show. If care advocates take issue with a case, they can elevate it to a peer review, which can result in a denial.
Care advocates are even calling therapists from the same phone number.
Overseen by the former director of ALERT, the team's more than 50 care advocates are tasked with ensuring that "outpatient care follows clinical and coverage guidelines" and "reduces overutilization and benefit expense when appropriate," according to company documents.
The team conducts thousands of reviews each month, targeting plans that are mostly regulated by states and fall outside of the jurisdictions of previous sanctions. Patients impacted include workers with fully insured plans and people covered by Medicaid.
Nearly 1 in 3 adults in the Medicaid program has a mental health condition, and a fifth of its members have a substance use disorder. "This is probably disproportionately sweeping up those that are most distressed, most ill and most in need of care," Clement said.
Private insurers that manage Medicaid plans, also known as managed care organizations, are often paid a fixed amount per person, regardless of the frequency or intensity of services used. If they spend less than the state's allotted payment, plans are typically allowed to keep some or all of what remains. Experts, senators and federal investigators have long raised concerns that this model may be incentivizing insurers to limit or deny care.
"They basically manage the benefits to maximize their short-term profit," said David Lloyd, chief policy officer with the mental health advocacy group Inseparable and an expert on state-level mental health parity laws.
State regulators are supposed to be making sure private insurers that manage Medicaid plans are following the mental health parity laws. But this year, a federal audit found that they were failing to do so. "They are not well designed to essentially be watchdogs," Lloyd said. "There's very little accountability. Insurers can run roughshod over them."
The internal records reviewed by ProPublica show the plans and geographic areas now scrutinized by the rebranded program. The team conducts two types of reviews, those considered "consultation" and those that question medical necessity.
For the first kind, the team flags members with high use (more than 30 sessions in eight months) or high frequency (twice-a-week sessions for six weeks or more) to engage their providers in "collaborative" conversations about the treatment plan.
Company documents reveal striking similarities between Optum's ALERT and Outpatient Care Engagement programs. Credit: Obtained by ProPublica
Internal records indicate that the company uses this "consultation" model for about 20 state Medicaid programs, including Washington, Minnesota, Mississippi, Virginia and Tennessee. The company is also deploying the program with Medicaid plans in Massachusetts and, as of the fourth quarter of this year, New York, which are outside of the jurisdiction of the earlier state agreements.
While the Department of Labor does not have jurisdiction over Medicaid, a spokesperson said it "would be concerned about ‘consultation' reviews that are conducted in a way that violates [the mental health parity act]." The department did not comment on whether it was investigating the insurer, as a matter of agency policy.
Company records show Optum is applying its more stringent review method, questioning medical necessity, to psychological testing services and a type of therapy to treat children with autism, known as applied behavior analysis, for people with Medicaid coverage in about 20 states. It is doing the same for routine therapy for its members with dual Medicare-Medicaid plans in about 18 states and Washington, D.C. Such plans are largely overseen by the Centers for Medicare & Medicaid Services, the federal agency responsible for overseeing both Medicare and Medicaid programs. While the dual plans are not subject to federal mental health parity laws, a CMS spokesperson said the agency was taking steps to "ensure that people enrolled in these plans have timely access to care."
The internal company records reveal that Optum has continued to use quotas with its medical necessity reviews, setting productivity targets for how many cases its employees scrutinize. According to records from this year, the target was 160 reviews per employee, which the company exceeded with 180 reviews per employee.
Several state agencies that oversee Medicaid programs, including those in New York and Massachusetts, told ProPublica that they follow federal mental health parity laws and have strong monitoring practices to ensure that the private insurers that manage benefits are in compliance.
Katie Pope, a spokesperson for Washington's healthcare Authority, told ProPublica that ALERT was discontinued three years ago but did not directly respond to questions about the current iteration of the program. Scott Peterson, a spokesperson for Minnesota's Human Services Department, said that while United's policies were compliant with federal parity laws, the company's contract would expire at the end of the year. Last May, the state blocked for-profit insurers, like United, from participating in its Medicaid program.
Amy Lawrence, a spokesperson for Tennessee's Medicaid program, said United's outlier review practice entailed "voluntary collaborative conversations on best practices" and did not question the medical necessity of services nor result in denials of treatment. "There are no adverse consequences for providers who elect not to participate," she said.
Mississippi's, Louisiana's and Virginia's state Medicaid agencies did not respond to ProPublica's questions. (Read all state responses.)
In response to ProPublica's questions about its oversight of state Medicaid programs, a spokesperson for CMS said it was "actively engaged with states and other stakeholders to improve compliance and oversight of parity requirements." (Read the full responses of federal agencies.)
Hauser, the spokesperson for Optum, told ProPublica that the company is committed to working with state Medicaid programs to ensure access to effective and necessary care. She said its new program was separate from ALERT, which she said had been discontinued. (She did not explain why the original ALERT program appears to be still operational in Louisiana, according to a recent company manual.) When the team conducts medical necessity reviews, she said, they are compliant with mental health parity law. (Read the company's full response.)
Ringing Phones
Therapists who underwent the reviews told ProPublica that they felt the practice was intended to discourage them from providing necessary care, interfering with their ability to treat their patients.
This year, Oklahoma therapist Jordan Bracht received multiple calls from the team related to the care of two patients, who were both on United's dual Medicare-Medicaid plan. "If we don't hear back from you within a week," a care advocate said in a voice message, "then the case will be forwarded to the peer review process to make a decision based upon the information available."
Both of Bracht's patients had diagnoses of dissociative identity disorder and required therapy twice a week. "Many of my clients are suicidal and would be hospitalized if I had to cut down the care," Bracht told ProPublica.
Reviewers pushed for end dates for their therapy. "They really wanted me to nail down a discharge date," she said. "We are really trying to keep this person alive, and it felt like they were applying their one-size-fits-all model. It doesn't feel right."
Virginia therapist Chanelle Henderson got a voice message in 2022 from the same number about her care of a patient with state Medicaid coverage. "We'd like to complete a clinical review," the caller said. "We'll follow up with one more call before the case is referred to the peer review process."
When Henderson called back, a reviewer informed her that her practice had been flagged for providing longer sessions. Henderson tried to explain they were necessary to treat trauma, her practice's specialty. "She had no trust in me as a clinician," Henderson said of the reviewer.
The inquiry progressed to questions about other patients, including one who was being treated by a therapist under Henderson's supervision. The reviewer said that the company did not cover sessions of supervised therapists at practices with less than 12 therapists. At the time, Henderson's practice had eight.
The reviewer elevated her case, triggering an aggressive audit of the entire practice going back two years that threatened to shut it down.
Citing issues with supervision and longer sessions, United demanded the practice pay back about $20,000 for services it had already provided. Henderson and her business partner pushed back, hiring a biller to help submit hundreds of pages of additional notes and documentation. They also pointed out that during the audit, the company had even changed its policy to allow smaller practices to supervise therapists. United eventually decreased the penalty by half. Neither Optum, United nor Virginia's Medicaid program directly responded to ProPublica's questions about the case.
Bethany Lackey, who co-founded the practice with Henderson, said that the reviews felt like a pretext for additional scrutiny. "It's all set up in order to catch someone doing something so that they can take back payments," she said. "We all know that behind it is this more malicious intent of getting their money back."
We're Investigating Mental healthcare Access. Share Your Insights.
ProPublica's reporters want to talk to mental health providers, health insurance insiders and patients as we examine the U.S. mental healthcare system. If that's you, reach ou
For three years during the coronavirus pandemic, the federal government gave Texas and other states billions of dollars in exchange for their promise not to exacerbate the public health crisis by kicking people off Medicaid.
When that agreement ended last year, Texas moved swiftly, kicking off more people faster than any other state.
Officials acknowledged some errors after they stripped Medicaid coverage from more than 2 million people, most of them children. Some people who believe they were wrongly removed are desperately trying to get back on the state and federally funded health care program, adding to a backlog of more than 200,000 applicants. A ProPublica and Texas Tribune review of dozens of public and private records, including memos, emails and legislative hearings, clearly shows that those and other mistakes were preventable and foreshadowed in persistent warnings from the federal government, whistleblowers and advocates.
Texas' zealousness in removing people from Medicaid was a choice that contradicted federal guidelines from the start. That decision was devastating in Texas, which already insures a smaller percentage of its population through Medicaid than almost any other state and is one of 10 that never expanded eligibility after the passage of the Affordable Care Act.
"The difference in how Texas approached this compared to a lot of other states is and was very striking. It wanted everybody off, anybody extra off, even though we knew that meant that state systems would buckle under the pressure," said Erin O'Malley, a senior policy analyst with Every Texan, a left-leaning statewide advocacy group.
Medicaid rolls swelled nationally during the pandemic, with tens of millions of people added to the program and no one removed. In Texas, the number of people receiving Medicaid benefits grew by more than 50%, to 6 million. When the federal government stopped requiring continuous coverage in April 2023, states had to determine who was no longer eligible.
The question wasn't whether to remove people but instead how to do it in a way that caused the least disruption and ensured those who qualified stayed on.
To that end, the federal Centers for Medicare and Medicaid Services advised states to proceed slowly and rely heavily on existing government data to automatically renew eligible residents, steps the agency believed would prevent poor families from wrongly losing coverage. Congress gave states a year for the so-called "Medicaid unwinding."
But Texas opted for speed, launching reviews of about 4.6 million cases in the first six months. It also decided against the more vigorous use of automatic renewals urged by the federal government, forcing nearly everyone to resubmit documents proving they qualified. Nearly 1.4 million of those who lost coverage were disenrolled for bureaucratic reasons like failing to return a form or completing one incorrectly, not because they weren't eligible.
The decision to buck federal government guidelines was one of many that led to serious repercussions for Texas residents who rely on the program.
Among them were children forced to forgo or postpone lifesaving operations such as heart surgeries, said Dr. Kimberly Avila Edwards, an Austin pediatrician and Texas representative for the American Academy of Pediatrics. Children with severe diseases such as sickle cell anemia, as well as those with neurodevelopmental delays and autism, also unnecessarily lost critical care.
One of her colleagues treated a boy with a rare heart condition who lost Medicaid coverage in January after his parents failed to sign a form that even his caseworker was not aware the family needed to complete.
The boy's parents couldn't afford his $6,000 monthly pulmonary hypertension medication, nor could they pay for an ultrasound that would help determine whether he could survive without the drugs, said Avila Edwards, who declined to identify him because of medical privacy laws.
"If we have children who are less healthy, who are unable to get the preventative care they need for their chronic medical conditions, that fundamentally should raise concern for all of us," she said.
The boy was eventually reenrolled in Medicaid after Texas pediatricians persuaded the state health agency to restore his coverage, Avila Edwards said.
Thomas Vasquez, a spokesperson for the Texas Health and Human Services Commission, acknowledged that the agency "learned many lessons" and is working to improve eligibility processes. HHSC representatives defended the rollout, saying that the agency conducted community outreach and hired more than 2,200 employees.
Texas' approach to the Medicaid unwinding reflected the state's long-standing conservative ideology regarding the government-subsidized program, said Simon Haeder, an associate professor at Texas A&M University's School of Public Health.
As attorney general more than a decade ago, Gov. Greg Abbott helped lead a successful lawsuit against the federal government to ensure states didn't have to cover more residents under Medicaid as part of the Affordable Care Act. Since then, Abbott and state lawmakers have continued to severely limit the program to mostly children, pregnant women and disabled adults. Poor adults aren't typically eligible for Medicaid unless they have children. Parents of two kids must earn a combined income of less than $285 monthly to qualify for coverage.
A spokesperson for Abbott declined an interview on his behalf and did not respond to a request for comment on the state's handling of the unwinding.
Texas' stance during the unwinding, Haeder said, was, "We don't do anything illegal, but we want to get our program as fast as we can down to what it was before the pandemic."
Ignored Warnings
It was inevitable that the COVID-19 public health emergency would eventually end, as would the prohibition against pushing people off the rolls. Federal officials worried about the effects of the unwinding on vulnerable Americans almost from the start. In fact, the Biden administration repeatedly extended the emergency declaration, even after the peak of the crisis, to maintain safeguards that included keeping millions of low-income people on Medicaid.
Once the emergency officially ended in April 2023, states were free to cull their rolls. In preparation, federal officials advised states not to review more than 11% of their caseloads each month, cautioning that moving more quickly could overwhelm their systems and lead to the wrongful removal of eligible people.
But that was guidance, not a requirement, and Texas chose a far more aggressive plan.
In the first month of the unwinding, the state started the review process for about a million cases, or 17% of its caseload.
The federal government in May 2023 pressed Texas on why the state was moving so quickly. State officials downplayed the concerns, writing in an email obtained by the news organizations that they were frontloading people who most likely no longer qualified and were reviewing entire households at once.
Within the first four months of the unwinding, the state dropped more than 600,000 people from Medicaid. The vast majority were removed not because the state determined they were no longer eligible but for reasons such as failing to provide the proper documents in time.
That July, U.S. Health and Human Services Secretary Xavier Becerra called on Texas and other states to increase the number of eligible people they automatically renewed with existing government data. He warned in a letter that his agency would take action against states that were not complying.
In the same week, a group of employees anonymously emailed HHSC Executive Commissioner Cecile Young and media organizations, claiming senior management had alerted them that tens of thousands of people had improperly lost Medicaid due to the agency's poor handling of the unwinding. Young's chief of staff responded in an email that she couldn't address the allegations of unidentified whistleblowers.
Texas alerted the federal government days later that it had erroneously dropped nearly 100,000 people, according to records obtained by the news organizations.
In August 2023, CMS once again implored the state to stop requiring eligible people to resubmit paperwork proving they still qualified. The federal agency said it appeared that many people didn't know they needed to reenroll, didn't understand the forms or faced obstacles in submitting the required information.
Other states that had taken a similar approach, such as Pennsylvania and Maine, made significant changes. Not Texas.
The state agency flagged to CMS last September that more than 30,000 kids lost their coverage, even though most of them should have been moved from Medicaid to the Children's Health Insurance Program, according to emails the news organizations obtained through the state's Public Information Act.
State officials later told the news organizations that 95,000 people had been wrongly removed, instead of close to 130,000, as originally reported to CMS. Asked why the figures had decreased, a spokesperson said the agency "provided approximate numbers as we worked to resolve the issue." Agency representatives said the state quickly reinstated coverage and implemented changes to prevent further improper denials. They did not provide specifics.
Alarmed by the deluge of disenrollments, advocacy groups, health providers and newspaper editorial boards began calling on the state last summer to pause the unwinding and ensure people were not incorrectly losing coverage. It did not do so.
In October, after Texas had already disenrolled more than 1.2 million people, the state gave about 400,000 people who likely qualified for Medicaid an extra month to submit paperwork, according to an agency spokesperson.
Still, problems persisted.
In December, Becerra appealed directly to Abbott and eight other governors of states with the highest shares of children who had lost coverage. Texas accounted for nearly a quarter of all children in the U.S. who had lost Medicaid or CHIP during the unwinding, Becerra wrote. He again urged the state to employ a series of actions, including automatically renewing eligible people.
Without providing details, Becerra said the federal government would not hesitate to take action against states that did not comply with federal requirements.
'A One-Two Punch'
Three months later, Micaela Hoops' children lost the government-subsidized health insurance for which they had qualified their entire lives. After years of not having to renew their Medicaid coverage under the pandemic rules, the 37-year-old North Texas mother said she was confused about when she was required to reapply and missed the deadline to provide proof of the family's income.
In other states, the kids might have been automatically renewed using other government information, like quarterly payroll data reported by employers to the state or federal tax records. Instead, Hoops had to frantically reapply seven days after the coverage lapsed in March, submitting 24 pay statements for her husband's weekly wages as a marketing director for a real estate company. This put the family at the back of a monthslong waiting list.
During that time, Hoops, a stay-at-home mom who homeschools the children, had to take her eldest son to the emergency room for a debilitating migraine. The visit came with a $3,000 bill that she and her husband could not pay. A few months later, the 14-year-old broke his nose while playing with his brother on a trampoline. She paid a few hundred dollars out of pocket for the doctor but couldn't afford the CT scan required to reset his nose.
More than 100 days after Hoops reapplied, the state restored her children's coverage retroactively. She hopes Medicaid will cover the hospital visit, but her son's nose remains crooked.
"My children didn't deserve to go without insurance," Hoops said. "They're kids. They have medical emergencies, things happen, and they deserve to be taken care of."
While Hoops' children got their Medicaid back, some families that believe they wrongly lost Medicaid are still waiting after being forced to reapply. Texas' median processing time for Medicaid applications is almost three months, according to a recent agency briefing obtained by the news organizations. This exceeds the federal limit of 45 days for most cases.
The sudden suspension of health insurance for a population the size of New Mexico has had additional ramifications in Texas, including higher treatment costs for hospitals and clinics forced to take on more uninsured patients.
Texas Children's Hospital in Houston, the largest pediatric hospital in the country, laid off employees this year after significant budget shortfalls. A hospital spokesperson declined to comment, but, in a recent financial filing, the hospital attributed some of the challenges to losing Medicaid patients during the state's unwinding process.
Across the state, some safety net clinics reported a 30% decrease in Medicaid revenue due to the unwinding, said Jana Eubank, who heads the Texas Association of Community Health Centers. She said the extra costs added to challenges for the already financially strapped facilities.
"Some centers are having to lay off staff. Some centers are furloughing staff," Eubank said. "I've got a couple of CEOs that aren't taking a salary right now. I've had centers that are unfortunately having to cut back certain services or extended hours, like behavioral health services, dental services, just because they can't afford to continue to offer that care."
Separately, some families that were pushed off Medicaid are also waiting more than a month for food assistance because Texas uses the same eligibility system to process applications for both.
San Antonio Food Bank CEO Eric Cooper said the nonprofit was crushed by demand this summer when families faced sudden medical bills, kids were out of school and the state had a backlog of more than 277,000 food stamp applications. The situation worsened when Texas declined to participate in a federal nutrition program, turning down an estimated $450 million that could have helped feed nearly 3.8 million poor children during the summer. HHSC officials said they could not get the program running in time.
"It's felt like a one-two punch, the double whammy," Cooper said.
"We haven't really felt any relief since the Medicaid unwinding and the official end of the public health emergency," he added. "It's still an emergency. It's still a crisis."
Federal Investigation
In May, after Texas' unwinding ended, the federal government launched an investigation into long waits faced by people who had applied for Medicaid coverage. Addressing these persistent delays was especially important because they affected eligible people who lost coverage in the past year, Sarah deLone, director of CMS' Children and Adults Health Programs Group, wrote in a letter to the state.
Former federal officials and health policy experts called the probe a significant step by the agency, which typically works with states behind the scenes.
But CMS has few options to hold Texas accountable if it finds wrongdoing, said Joan Alker, executive director of the Center for Children and Families at Georgetown University in Washington, D.C. The Biden administration's major enforcement tool is yanking federal funding, but that could cause low-income people to lose health insurance and invite a lawsuit from Texas, Alker said. And the investigation likely won't go anywhere if Donald Trump wins in November, she said, since the former president previously encouraged states to restrict Medicaid access and promised to undo the Affordable Care Act entirely.
CMS spokesperson Stephanie Rossy declined to comment directly on its investigation or on Texas' handling of the unwinding. But in a statement she wrote that "states' choices have real consequences for eligible people's ability to stay covered."
Texas officials also declined to discuss the probe, but in a letter to the federal agency two weeks after the May investigation announcement, the state's Medicaid director, Emily Zalkovsky, acknowledged that Texas experienced "severe operational and systems challenges" during the unwinding.
Although the federal probe was welcomed by advocacy groups, as well as some health care providers and Texas families, it's unlikely to immediately help eligible people who lost Medicaid during the unwinding and are waiting to get back on.
While Hoops' children have regained coverage, she believes that what her family endured reflects state leaders' attitudes toward low-income people.
"Maybe they didn't realize they were making cruel decisions," she said. Still, she feels like the state's mentality is basically, "Well, you just shouldn't be dependent on us."
The Food and Drug Administration issued a rule on Monday that brings new scrutiny to a vast array of critical lab tests, including some popular prenatal genetic screenings, that reach patients without any federal agency checking to ensure they work the way their makers claim.
"This is a significant step forward," said Peter Lurie, president and executive director of the Center for Science in the Public Interest and a former FDA associate commissioner. These tests have "always been one of the remaining gaping holes in the FDA regulatory structure. And it's great to see that the agency has taken concrete steps to close it."
The move comes after decades of debate and stalled legislation on LDTs, which also include certain cancer screenings as well as some tests for rare diseases. Because these tests are designed, manufactured and used in a single lab, they escape most federal oversight over marketing and accuracy.
A large coalition of labs, associations and academic medical centers have long pushed back on the prospect of increased FDA involvement in these tests. It would be too onerous, they've argued, and it jeopardizes patient access to health services.
One of nearly 7,000 comments submitted in response to the draft rule came from the Association for Molecular Pathology, representing a wide-ranging group of professionals associated with laboratory testing. The FDA's proposed changes "would result in laboratory professionals being treated as product manufacturers instead of board-certified healthcare providers," the association's president wrote, and it would "unequivocally hinder and harm patient care."
The agency's hands-off approach dates back to an era when these tests were a relatively small, low-risk sector of the health care system. Now, they are a much bigger player and include high-stakes tests made by commercial companies. While the Centers for Medicare and Medicaid Services reviews lab operations, it doesn't check whether the tests themselves are clinically valid. The tests aren't registered with the federal government, so nobody knows how many exist. In 2021, Pew Charitable Trusts estimated that 12,000 labs are likely to deploy them, many of which process thousands a day.
The ProPublica story on prenatal genetic screenings referenced by the FDA revealed how the agency didn't check the tests before they reached patients or evaluate marketing claims made by the companies that sell them. Companies aren't required to publicly report when a test gets it wrong, the investigation found, and no federal agency can recall faulty screenings. The story detailed how false positives, false negatives and indeterminate results can have painful consequences for expecting parents. (We also published a guide to the prenatal tests to help families with their questions.)
Our coronavirus investigation showed how a Chicago-based company with state and local contracts in Nevada sold testing services that were unreliable from the start. As it became clear that the lab was telling infected people that they had tested negative for the virus, company officials nonetheless expanded the reach of the lab's testing. The company declined to comment for ProPublica's previous stories on these problems.
The rule will go into effect over a four-year period. Within two years, test-makers will be expected to meet registration and listing requirements, among others, which is "a critical part of this rule," according to Cara Tenenbaum, a former FDA policy adviser whose consultancy has advocated for more active oversight.
"At least knowing what is out there will be huge," she said in an email.
High-risk tests will need to meet new FDA review requirements before reaching the marketplace starting in November 2027. Moderate-risk and low-risk tests will need to do the same starting in May 2028. It's unclear how prenatal screening tests would be categorized.
The agency generally will not enforce some or all requirements for certain LDTs, including tests that were first marketed before the rule was issued and have not since been modified or have been modified in certain limited ways.
The agency will also generally not enforce some or all requirements for tests used within the Veterans Health Administration or the Department of Defense, as well as certain tests that meet other narrow conditions.
Nonetheless, the rule marks a massive shift in the FDA's approach to a sector that touches millions. "The agency cannot stand by while Americans continue to rely on results of these tests without assurance that they work," FDA commissioner Robert Califf said in an agency news release.
The final rule, he added, aims to "help ensure that important health care decisions are made based on test results that patients and health care providers can trust."
The FDA tried to rein in the lab tests a decade ago, issuing a draft guidance in 2014. That prompted a two-year backlash from opponents. The agency ultimately dropped it.
Laurie Menser, chief executive of the Association for Molecular Pathology, said in an emailed statement that the association is "very disappointed" in the new rule.
"It's unfortunate the agency continues to overstep its authority and bypass the country's legislative process," Menser said. "AMP is currently reviewing the different aspects of the rule and assessing the many implications for our members and patient care."
Lurie, who was closely involved with the FDA effort to address the tests a decade ago, said the rule has been a long time coming. "People had identified this problem a very long time ago, and wanted to take action, but found themselves stymied by opposition," he said.
"I think that it shows real courage on the part of the agency, as well as commitment to the public health, to take this step," he added.
Anna.clark@propublica.org is a Detroit-based reporter for ProPublica, covering stories in Michigan and the Midwest. She is the author of "The Poisoned City: Flint's Water and the American Urban Tragedy.
Cigna tracks every minute that its staff doctors spend deciding whether to pay for healthcare. Dr. Debby Day said her bosses cared more about being fast than being right.
This article was published on Monday, April 29, 2024 in ProPublica.
In late 2020, Dr. Debby Day said her bosses at Cigna gave her a stark warning. Work faster, or the company might fire her.
That was a problem for Day because she felt her work was too important to be rushed. She was a medical director for the health insurer, a physician with sweeping power to approve or reject requests to pay for critical care like life-saving drugs or complex surgeries.
She had been working at Cigna for nearly 15 years, reviewing cases that nurses had flagged for denial or were unsure about. At Cigna and other insurers, nurses can greenlight payments, but denials have such serious repercussions for patients that many states require that doctors make the final call. In more recent years, though, Day said that the Cigna nurses' work was getting sloppy. Patient files that nurses working in the Philippines sent to her, she said, increasingly had errors that could lead to wrongful denials if they were not corrected.
Day was, in her own words, persnickety. If a nurse recommended denying coverage for a cancer patient or a sick baby, she wanted to be certain it was the right thing to do. So Day said she researched guidelines, read medical studies and scrutinized patient medical records to come to the best decision. This took time. She was clearing fewer cases than many of her peers.
Some of her colleagues quickly denied requests to keep pace, she said. All a Cigna doctor had to do was cut and paste the denial language that the nurse had prepared and quickly move on to the next case, Day said. This was so common, she and another former medical director said, that people inside Cigna had a term for these kinds of speedy decisions: "click and close."
In late 2020, Dr. Debby Day said her bosses at Cigna gave her a stark warning. Work faster, or the company might fire her.
That was a problem for Day because she felt her work was too important to be rushed. She was a medical director for the health insurer, a physician with sweeping power to approve or reject requests to pay for critical care like life-saving drugs or complex surgeries.
She had been working at Cigna for nearly 15 years, reviewing cases that nurses had flagged for denial or were unsure about. At Cigna and other insurers, nurses can greenlight payments, but denials have such serious repercussions for patients that many states require that doctors make the final call. In more recent years, though, Day said that the Cigna nurses' work was getting sloppy. Patient files that nurses working in the Philippines sent to her, she said, increasingly had errors that could lead to wrongful denials if they were not corrected.
Day was, in her own words, persnickety. If a nurse recommended denying coverage for a cancer patient or a sick baby, she wanted to be certain it was the right thing to do. So Day said she researched guidelines, read medical studies and scrutinized patient medical records to come to the best decision. This took time. She was clearing fewer cases than many of her peers.
Some of her colleagues quickly denied requests to keep pace, she said. All a Cigna doctor had to do was cut and paste the denial language that the nurse had prepared and quickly move on to the next case, Day said. This was so common, she and another former medical director said, that people inside Cigna had a term for these kinds of speedy decisions: "click and close."
"Deny, deny, deny. That's how you hit your numbers," said Day, who worked for Cigna until the late spring of 2022. "If you take a breath or think about any of these cases, you're going to fall behind."
In a written response to questions, Cigna said its medical directors are not allowed to "rubber stamp" a nurse's recommendation for denial. In all cases, the company wrote, it expects its doctors to "perform thorough, objective, independent and accurate reviews in accordance with our coverage policies." The company said it was unaware of the use of the term "click and close" and that "such behavior would not be tolerated."
During Day's final years at Cigna, the company meticulously tracked the output of its medical directors on a monthly dashboard. Cigna shared this spreadsheet with more than 70 of its doctors, allowing them to compare their tally of cases with those of their peers. Day and two other former medical directors said the dashboard sent a message loud and clear: Cigna valued speed. (ProPublica and The Capitol Forum found these other former Cigna doctors independently; Day did not refer them.) One of Day's managers in a written performance evaluation called the spreadsheet the "productivity dashboard."
Measuring the speed and output of employees is common in many industries, from fast food to package delivery, but the use of these kinds of metrics in health care is controversial because the stakes are so high. It's one thing if a rushed server forgets the fries with your burger. It's another entirely if the pressure to act fast leads to wrongful denials of payment for vital care. Walgreens in 2022 dropped measurements of its pharmacists' speed from their performance reviews after some alleged that practice could lead to dangerous mistakes.
ProPublica and The Capitol Forum examined Cigna's productivity dashboards for medical directors from January and February 2022. These spreadsheets tallied the number of cases each medical director handled. Cigna gave each task a "handle time," which the company said was the average amount of time it took its medical directors to issue a decision.
Day and others said the number was something different: the maximum amount of time they should spend on a case. Insurers often require approval in advance for expensive procedures or medicines, a process known as prior authorization. The early 2022 dashboards listed a handle time of four minutes for a prior authorization. The bulk of drug requests were to be decided in two to five minutes. Hospital discharge decisions were supposed to take four and a half minutes.
"Medical directors would message me and say, 'We can't do these cases in four minutes. Not if you want to do a good job,'" Day recalled.
As ProPublica and The Capitol Forum reported last year, Cigna built a computer program that allowed its medical directors to deny certain claims in bulk. The insurer's doctors spent an average of just 1.2 seconds on each of those cases. Cigna at the time said the review system was created to speed up approval of claims for certain routine screenings; the company later posted a rebuttal to the story. A congressional committee and the Department of Labor launched inquiries into this Cigna program. A spokesperson for Rep. Cathy McMorris Rodgers, the chair of the congressional committee, said Rodgers continues to monitor the situation after Cigna shared some details about its process. The Labor Department is still examining such practices.
One figure on Cigna's January and February 2022 dashboards was like a productivity score; the news organizations found that this number reflects the pace at which a medical director clears cases.
Cigna said it was incorrect to call that figure on its dashboard a productivity score and said its "view on productivity is defined by a range of factors beyond elements included in a single spreadsheet." In addition, the company told the news organizations, "The copy of the dashboard that you have is inaccurate and secondary calculations made using its contents may also be inaccurate." The news organizations asked what was inaccurate, but the company wouldn't elaborate.
Nevertheless, Cigna said that because the dashboard created "inadvertent confusion" the company was "reassessing its use."
Day was afraid to look at the dashboards. Anyone could see that by Cigna's measures, she was a laggard. In January 2022, only a third of her peers had lower scores, and in February 2022, it was just a quarter.
In a recorded phone call and in emails with supervisors, Day complained that Cigna's metrics failed to account for the quality of decisions. She said she and others asked higher-ups how often medical director decisions were overturned on appeal but nobody would say.
Day gave Cigna written permission to discuss her employment with ProPublica and The Capitol Forum.
The company described Day as a "disgruntled former employee" and said her "personal view is not an accurate representation of the work of the many medical directors and clinicians we employ." Cigna added that prior authorization requests are often time-sensitive and the company's "mission is to ensure our patients receive the right care as quickly as possible."
Cigna rejected the assertions that denying cases was an effective way of working faster. "Even if medical directors were incentivized to review more claims — which they are not — it makes no sense to suggest that this incentivizes denials; it would be far quicker to approve all claims," the company spokesperson wrote. The insurer said that denials take more time because they require a deeper review of clinical data, potentially requesting additional reviews by senior clinical directors, drafting denial letters and possibly phoning the treating physicians.
But another doctor who had worked at Cigna also said that denying a request for payment was far quicker than approving one since the nurses served up language that could be used to justify the denial. That former Cigna medical director said, "Sometimes you just have to accept the nurse and click and close if you had too much work." (That doctor asked not to be named because they feared repercussions if they commented publicly.)
When Debby Day got her job at Cigna in November 2005, she thought it was a godsend.
She had been working for a health insurance startup in North Carolina. The charismatic founder of the company, Day said, had told her and a handful of principal executives to expect a windfall when the company went public. That never happened, and Day was eventually left with no job and no severance.
When a recruiter mentioned the medical director job at Cigna, it sounded like a perfect fit. The job was based in North Carolina, but Cigna didn't mind that she was licensed in California, where she did her residency at Harbor-UCLA Medical Center. She was ready to leave the executive track, and the position allowed her to put her medical training to good use without the daily grind of working in a clinic.
The daughter of an ophthalmologist, Day had watched her father perform eye surgery when she was a child, and she found medicine fascinating. When Day started practicing, she learned quickly that while she enjoyed the intellectual challenges of medicine, the hands-on work of seeing patients drained her. As a medical director, she said, "I could really take care of patients without having to talk to them all day long."
Cigna, like all health insurers, makes patients get approval in advance for certain treatments. Day became one of the people who reviewed these prior authorization requests, deciding what to cover and what to deny. Everyone Day worked with was under one roof in Raleigh, North Carolina. The office buzzed with conversations among colleagues, and she was able to consult with specialists on complex cases.
She never felt pressure to do anything but make the right decision for the patient. At the same time, she said, she didn't hesitate to reject treatment she thought was improper.
Day describes herself as persnickety but feels that the time she spent reviewing case files was essential to reaching the right decision. Credit:Andrea Bruce for ProPublica
A couple years into her time at Cigna, Day noticed some doctors prescribing a costly treatment called intravenous immunoglobulin, or IVIG, that helps patients with weakened immune systems fight off infections. Only she found they were prescribing it in cases where it didn't make any medical sense. That wasn't good for patients or for Cigna. "Some of these guys were pouring it into every patient they could get their hands on and then making hundreds of thousands of dollars billing for it," she recalled.
At the time, Cigna didn't have a policy for when IVIG should be used, so Day developed one based on the scientific evidence available at the time. Day said this saved millions of dollars and that Cigna rewarded her with bonuses and stock options.
"In my head I truly believed that you could marry good health care with business," she said.
As Day neared the end of her first decade at Cigna, the company closed regional offices in favor of a nationwide review system, she said. With medical directors working from home, Day could no longer pop down the hallway to consult with doctors in other specialities.
Cigna had used a productivity dashboard for years, but by 2019, these metrics began playing a more prominent role in the company's evaluations of medical directors, Day said. Now, making a fast decision seemed more important than making the right decision, she said. In February 2019 emails to her managers, Day openly questioned this system.
Her boss responded: "We all understand that many cases are involved and take more time," he wrote. "We have tried to account for that additional time in the allotment allowed for certain cases."
Still, he made it clear that transaction volume — the metric on the dashboard that was similar to a productivity score — was one of the factors "we use to determine merit raises, bonus" and stock awards. When asked about this, Cigna said that "any assertion that our Medical Directors' compensation (cash or stock) is tied to denials or their handle time for cases is false."
In that same 2019 email, Day's boss added, "We want to assist every medical director who wishes to improve his or her efficiency."
Day shot back, "Some of our newer MDs are quite terrified of the 'counting,'" she wrote. "All ask — 'how is quality measured?'"
Soon, Day realized that her boss wasn't talking in the abstract about improving efficiency; he was talking about her. She learned that managers were going to help her pick up the pace of her reviews.
When bosses reached out, they didn't discuss whether she was making the right call, only how long it took her to decide, she said.
By then, Day said, Cigna had shifted much of the nursing work to the Philippines. She found mistakes in the case files that these nurses sent. In an email to Day, a fellow medical director lamented the amount of time it took to untangle one case and said the reports by "the overseas nurses" were "messes."
Some of the more astonishing problems that Day spotted have stayed with her. In a case involving a newborn who needed an epilepsy evaluation, Day noticed that a Cigna nurse had listed the mother's name as the patient, rather than the baby's. Day fixed that mistake, avoiding what certainly would have been a denial. In another case, a nurse recommended denying payment for an ultrasound of the neck because the treatment wasn't medically necessary. But the nurse had gotten the body part wrong. It was a hip that was injured, and the imaging was needed. An appeal that landed on Day's desk involved Cigna's decision to reject payment for a test because it wasn't medically necessary for a patient with a sexually transmitted disease. But Day figured out that the patient had toenail fungus, not an STD.
Day said her bosses didn't want to hear that she was catching errors. By October 2020, Cigna had placed Day on a performance improvement plan that required her to raise her "productivity level" — referring to the score on the dashboard — to at least 70%, which would be a significant jump for her but was slightly below the median for medical directors. The company made the consequences crystal clear: If she failed to successfully complete the plan, she could be terminated.
ProPublica and The Capitol Forum asked Cigna how it calculated that score, but the company wouldn't say. "Transaction volume helps gauge productivity and efficiency — the amount of work done, not the speed at which it is done," a Cigna spokesperson wrote. The company said this metric measured the time a medical director spent on tasks involving medical judgment versus other work, such as internal meetings or training.
On the early 2022 productivity dashboard, though, a different calculation could explain Day's score, and this math reflects how fast medical directors reviewed cases. ProPublica and The Capitol Forum multiplied the number of cases Day handled by the time Cigna allotted for each type of case, then divided that total by the hours she worked that month. The resulting percentage equaled her score. Medical directors who spent every available minute of their workdays clearing cases within the time constraints Cigna set would score at least 100%. Indeed, some medical directors had scores greater than 100%, meaning they cleared cases in even less than the allotted time. The newsrooms' formula accurately reproduced the scores of 87% of the Cigna doctors listed; the scores of all but one of the rest fell within 1 to 2 percentage points of the number generated by this formula. When asked about this formula, Cigna said it may be inaccurate but didn't elaborate.
Day said her bosses told her that the way to boost her score was to review more cases during her normal work hours.
Responding to questions, Cigna said the productivity dashboard was "primarily used to ensure that we have enough medical directors to perform the amount and type of work that needs to be done." It is not used, the company said, to evaluate the performance of medical directors or track the speed at which individual doctors do their work.
Cigna, however, later said of the dashboard that "in the unusual situation that a medical director is a significant outlier to peers performing similar types of reviews, managers might use this metric as one data point to understand and discuss the variance with the medical director." It also said Day was placed on a performance improvement plan "to help her meet the most basic standards to support patient care."
During the time Day spent on the performance improvement plan, she refused to change her approach, which she felt was necessary to make the right call.
In December 2020, she appealed to the human resources department, figuring that colleagues there would see that it was wrong to fire a medical director for taking care to decide critical medical questions.
She was wrong.
"You feel that the time constraints/metrics, which are in place to review these cases are unreasonable, for some cases are very complex consisting of multiple pages to review," a Cigna human resources employee wrote, summing up Day's feelings as the matter escalated.
And while Day's supervisor "appreciates your attention to detail," the human resources employee wrote, he "also realizes that there are metrics in place that he must hold everyone to."
When asked about this, Cigna said, "Dr. Day raised questions about her performance improvement plan through appropriate internal ethics channels available to all employees, and there was no wrongdoing found."
Eventually, the daily stress of being pushed to work faster coupled with the threat of being fired took a toll on Day. Sleepless and fighting depression, Day was at the breaking point.
"I actually sort of had a mental breakdown," she recalled.
On a recorded call with her boss about her lagging productivity score, Day brought the subject back to the quality of the decisions she was making. Her boss made it sound like Day was a broken record.
"We have the same discussion every time we talk," he said. While saying "nobody's asking you not to do quality work," her boss said, "you must know I just have to redirect our discussion."
But Day continued: "When there is no measurement of quality, then the discussion will continue to have that element to it."
The supervisor said he heard Day's concerns "loud and clear" but warned that "at the end of the day, we need to get your productivity up and we don't have a lot of time to do that."
The focus on metrics was proof Cigna was losing its way, Day told her boss. When she started working at Cigna 15 years earlier, there was a "commitment to quality and taking care of our customers." Day said that it was still important to her and other medical directors that "we go home at the end of the day and think we've done a good job for Cigna."
How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them
In a response to questions, Cigna said the supervisor, who works in California, was unaware that he was being recorded and that under that state's laws, it is illegal to record a private phone call without all parties' consent. Day said that she was in North Carolina during the call and that North Carolina law allows a person on a call to record without getting the consent of others.
Day took a monthslong leave from the job in mid-2021 that allowed her to work part time, and she found a therapist who helped her manage the depression. When she returned, Day said, it was more of the same.
In the late spring of 2022 she decided to retire from Cigna.
In a written response to questions, Cigna said its medical directors are not allowed to "rubber stamp" a nurse's recommendation for denial. In all cases, the company wrote, it expects its doctors to "perform thorough, objective, independent and accurate reviews in accordance with our coverage policies." The company said it was unaware of the use of the term "click and close" and that "such behavior would not be tolerated."
During Day's final years at Cigna, the company meticulously tracked the output of its medical directors on a monthly dashboard. Cigna shared this spreadsheet with more than 70 of its doctors, allowing them to compare their tally of cases with those of their peers. Day and two other former medical directors said the dashboard sent a message loud and clear: Cigna valued speed. (ProPublica and The Capitol Forum found these other former Cigna doctors independently; Day did not refer them.) One of Day's managers in a written performance evaluation called the spreadsheet the "productivity dashboard."
Measuring the speed and output of employees is common in many industries, from fast food to package delivery, but the use of these kinds of metrics in health care is controversial because the stakes are so high. It's one thing if a rushed server forgets the fries with your burger. It's another entirely if the pressure to act fast leads to wrongful denials of payment for vital care. Walgreens in 2022 dropped measurements of its pharmacists' speed from their performance reviews after some alleged that practice could lead to dangerous mistakes.
ProPublica and The Capitol Forum examined Cigna's productivity dashboards for medical directors from January and February 2022. These spreadsheets tallied the number of cases each medical director handled. Cigna gave each task a "handle time," which the company said was the average amount of time it took its medical directors to issue a decision.
Day and others said the number was something different: the maximum amount of time they should spend on a case. Insurers often require approval in advance for expensive procedures or medicines, a process known as prior authorization. The early 2022 dashboards listed a handle time of four minutes for a prior authorization. The bulk of drug requests were to be decided in two to five minutes. Hospital discharge decisions were supposed to take four and a half minutes.
As ProPublica and The Capitol Forum reported last year, Cigna built a computer program that allowed its medical directors to deny certain claims in bulk. The insurer's doctors spent an average of just 1.2 seconds on each of those cases. Cigna at the time said the review system was created to speed up approval of claims for certain routine screenings; the company later posted a rebuttal to the story. A congressional committee and the Department of Labor launched inquiries into this Cigna program. A spokesperson for Rep. Cathy McMorris Rodgers, the chair of the congressional committee, said Rodgers continues to monitor the situation after Cigna shared some details about its process. The Labor Department is still examining such practices.
One figure on Cigna's January and February 2022 dashboards was like a productivity score; the news organizations found that this number reflects the pace at which a medical director clears cases.
Cigna said it was incorrect to call that figure on its dashboard a productivity score and said its "view on productivity is defined by a range of factors beyond elements included in a single spreadsheet." In addition, the company told the news organizations, "The copy of the dashboard that you have is inaccurate and secondary calculations made using its contents may also be inaccurate." The news organizations asked what was inaccurate, but the company wouldn't elaborate.
Nevertheless, Cigna said that because the dashboard created "inadvertent confusion" the company was "reassessing its use."
Day was afraid to look at the dashboards. Anyone could see that by Cigna's measures, she was a laggard. In January 2022, only a third of her peers had lower scores, and in February 2022, it was just a quarter.
In a recorded phone call and in emails with supervisors, Day complained that Cigna's metrics failed to account for the quality of decisions. She said she and others asked higher-ups how often medical director decisions were overturned on appeal but nobody would say.
Day gave Cigna written permission to discuss her employment with ProPublica and The Capitol Forum.
The company described Day as a "disgruntled former employee" and said her "personal view is not an accurate representation of the work of the many medical directors and clinicians we employ." Cigna added that prior authorization requests are often time-sensitive and the company's "mission is to ensure our patients receive the right care as quickly as possible."
Cigna rejected the assertions that denying cases was an effective way of working faster. "Even if medical directors were incentivized to review more claims — which they are not — it makes no sense to suggest that this incentivizes denials; it would be far quicker to approve all claims," the company spokesperson wrote. The insurer said that denials take more time because they require a deeper review of clinical data, potentially requesting additional reviews by senior clinical directors, drafting denial letters and possibly phoning the treating physicians.
But another doctor who had worked at Cigna also said that denying a request for payment was far quicker than approving one since the nurses served up language that could be used to justify the denial. That former Cigna medical director said, "Sometimes you just have to accept the nurse and click and close if you had too much work." (That doctor asked not to be named because they feared repercussions if they commented publicly.)
When Debby Day got her job at Cigna in November 2005, she thought it was a godsend.
She had been working for a health insurance startup in North Carolina. The charismatic founder of the company, Day said, had told her and a handful of principal executives to expect a windfall when the company went public. That never happened, and Day was eventually left with no job and no severance.
When a recruiter mentioned the medical director job at Cigna, it sounded like a perfect fit. The job was based in North Carolina, but Cigna didn't mind that she was licensed in California, where she did her residency at Harbor-UCLA Medical Center. She was ready to leave the executive track, and the position allowed her to put her medical training to good use without the daily grind of working in a clinic.
The daughter of an ophthalmologist, Day had watched her father perform eye surgery when she was a child, and she found medicine fascinating. When Day started practicing, she learned quickly that while she enjoyed the intellectual challenges of medicine, the hands-on work of seeing patients drained her. As a medical director, she said, "I could really take care of patients without having to talk to them all day long."
Cigna, like all health insurers, makes patients get approval in advance for certain treatments. Day became one of the people who reviewed these prior authorization requests, deciding what to cover and what to deny. Everyone Day worked with was under one roof in Raleigh, North Carolina. The office buzzed with conversations among colleagues, and she was able to consult with specialists on complex cases.
She never felt pressure to do anything but make the right decision for the patient. At the same time, she said, she didn't hesitate to reject treatment she thought was improper.
A couple years into her time at Cigna, Day noticed some doctors prescribing a costly treatment called intravenous immunoglobulin, or IVIG, that helps patients with weakened immune systems fight off infections. Only she found they were prescribing it in cases where it didn't make any medical sense. That wasn't good for patients or for Cigna. "Some of these guys were pouring it into every patient they could get their hands on and then making hundreds of thousands of dollars billing for it," she recalled.
At the time, Cigna didn't have a policy for when IVIG should be used, so Day developed one based on the scientific evidence available at the time. Day said this saved millions of dollars and that Cigna rewarded her with bonuses and stock options.
"In my head I truly believed that you could marry good health care with business," she said.
As Day neared the end of her first decade at Cigna, the company closed regional offices in favor of a nationwide review system, she said. With medical directors working from home, Day could no longer pop down the hallway to consult with doctors in other specialities.
Cigna had used a productivity dashboard for years, but by 2019, these metrics began playing a more prominent role in the company's evaluations of medical directors, Day said. Now, making a fast decision seemed more important than making the right decision, she said. In February 2019 emails to her managers, Day openly questioned this system.
Her boss responded: "We all understand that many cases are involved and take more time," he wrote. "We have tried to account for that additional time in the allotment allowed for certain cases."
Still, he made it clear that transaction volume — the metric on the dashboard that was similar to a productivity score — was one of the factors "we use to determine merit raises, bonus" and stock awards. When asked about this, Cigna said that "any assertion that our Medical Directors' compensation (cash or stock) is tied to denials or their handle time for cases is false."
In that same 2019 email, Day's boss added, "We want to assist every medical director who wishes to improve his or her efficiency."
Day shot back, "Some of our newer MDs are quite terrified of the 'counting,'" she wrote. "All ask — 'how is quality measured?'"
Soon, Day realized that her boss wasn't talking in the abstract about improving efficiency; he was talking about her. She learned that managers were going to help her pick up the pace of her reviews.
When bosses reached out, they didn't discuss whether she was making the right call, only how long it took her to decide, she said.
By then, Day said, Cigna had shifted much of the nursing work to the Philippines. She found mistakes in the case files that these nurses sent. In an email to Day, a fellow medical director lamented the amount of time it took to untangle one case and said the reports by "the overseas nurses" were "messes."
Some of the more astonishing problems that Day spotted have stayed with her. In a case involving a newborn who needed an epilepsy evaluation, Day noticed that a Cigna nurse had listed the mother's name as the patient, rather than the baby's. Day fixed that mistake, avoiding what certainly would have been a denial. In another case, a nurse recommended denying payment for an ultrasound of the neck because the treatment wasn't medically necessary. But the nurse had gotten the body part wrong. It was a hip that was injured, and the imaging was needed. An appeal that landed on Day's desk involved Cigna's decision to reject payment for a test because it wasn't medically necessary for a patient with a sexually transmitted disease. But Day figured out that the patient had toenail fungus, not an STD.
Day said her bosses didn't want to hear that she was catching errors. By October 2020, Cigna had placed Day on a performance improvement plan that required her to raise her "productivity level" — referring to the score on the dashboard — to at least 70%, which would be a significant jump for her but was slightly below the median for medical directors. The company made the consequences crystal clear: If she failed to successfully complete the plan, she could be terminated.
ProPublica and The Capitol Forum asked Cigna how it calculated that score, but the company wouldn't say. "Transaction volume helps gauge productivity and efficiency — the amount of work done, not the speed at which it is done," a Cigna spokesperson wrote. The company said this metric measured the time a medical director spent on tasks involving medical judgment versus other work, such as internal meetings or training.
On the early 2022 productivity dashboard, though, a different calculation could explain Day's score, and this math reflects how fast medical directors reviewed cases. ProPublica and The Capitol Forum multiplied the number of cases Day handled by the time Cigna allotted for each type of case, then divided that total by the hours she worked that month. The resulting percentage equaled her score. Medical directors who spent every available minute of their workdays clearing cases within the time constraints Cigna set would score at least 100%. Indeed, some medical directors had scores greater than 100%, meaning they cleared cases in even less than the allotted time. The newsrooms' formula accurately reproduced the scores of 87% of the Cigna doctors listed; the scores of all but one of the rest fell within 1 to 2 percentage points of the number generated by this formula. When asked about this formula, Cigna said it may be inaccurate but didn't elaborate.
Day said her bosses told her that the way to boost her score was to review more cases during her normal work hours.
Responding to questions, Cigna said the productivity dashboard was "primarily used to ensure that we have enough medical directors to perform the amount and type of work that needs to be done." It is not used, the company said, to evaluate the performance of medical directors or track the speed at which individual doctors do their work.
Cigna, however, later said of the dashboard that "in the unusual situation that a medical director is a significant outlier to peers performing similar types of reviews, managers might use this metric as one data point to understand and discuss the variance with the medical director." It also said Day was placed on a performance improvement plan "to help her meet the most basic standards to support patient care."
During the time Day spent on the performance improvement plan, she refused to change her approach, which she felt was necessary to make the right call.
In December 2020, she appealed to the human resources department, figuring that colleagues there would see that it was wrong to fire a medical director for taking care to decide critical medical questions.
She was wrong.
"You feel that the time constraints/metrics, which are in place to review these cases are unreasonable, for some cases are very complex consisting of multiple pages to review," a Cigna human resources employee wrote, summing up Day's feelings as the matter escalated.
And while Day's supervisor "appreciates your attention to detail," the human resources employee wrote, he "also realizes that there are metrics in place that he must hold everyone to."
When asked about this, Cigna said, "Dr. Day raised questions about her performance improvement plan through appropriate internal ethics channels available to all employees, and there was no wrongdoing found."
Eventually, the daily stress of being pushed to work faster coupled with the threat of being fired took a toll on Day. Sleepless and fighting depression, Day was at the breaking point.
"I actually sort of had a mental breakdown," she recalled.
On a recorded call with her boss about her lagging productivity score, Day brought the subject back to the quality of the decisions she was making. Her boss made it sound like Day was a broken record.
"We have the same discussion every time we talk," he said. While saying "nobody's asking you not to do quality work," her boss said, "you must know I just have to redirect our discussion."
But Day continued: "When there is no measurement of quality, then the discussion will continue to have that element to it."
The supervisor said he heard Day's concerns "loud and clear" but warned that "at the end of the day, we need to get your productivity up and we don't have a lot of time to do that."
The focus on metrics was proof Cigna was losing its way, Day told her boss. When she started working at Cigna 15 years earlier, there was a "commitment to quality and taking care of our customers." Day said that it was still important to her and other medical directors that "we go home at the end of the day and think we've done a good job for Cigna."
In a response to questions, Cigna said the supervisor, who works in California, was unaware that he was being recorded and that under that state's laws, it is illegal to record a private phone call without all parties' consent. Day said that she was in North Carolina during the call and that North Carolina law allows a person on a call to record without getting the consent of others.
Day took a monthslong leave from the job in mid-2021 that allowed her to work part time, and she found a therapist who helped her manage the depression. When she returned, Day said, it was more of the same.
In the late spring of 2022 she decided to retire from Cigna.
