TPAs Adopt the “Goodfellas” Business Model, Senate Slams UnitedHealth’s Medicare Cash Grab, and How One Patient Can Cost $9.1 Million

Hey all,

Happy Tuesday! It appears the healthcare industry has officially traded the Hippocratic Oath for the omertà of organized crime, with third-party administrators running protection rackets that would make the cast of Goodfellas blush. Between UnitedHealth deploying AI to creatively inflate invoices and billing departments engaging in the kind of "creative accounting" that turns single patients into $9 million windfalls, the entire system is operating less like a care network and more like a highly efficient syndicate. At this rate, we might as well stop calling it "risk management" and start calling it what it really is: a shakedown with a deductible.

Enjoy the rundown!

Jacob Brody (Co-Founder & CEO, ZorroRX)

(HEALTH CARE un-covered) TPAs: The Goodfellas Running Employers’ Health Plans

Third-party administrators (TPAs) for self-insured employers are increasingly operating like organized crime syndicates, enriching themselves and their parent insurance giants through opaque fee structures rather than protecting plan assets. By utilizing gag clauses to withhold "proprietary" claims data, these entities conceal schemes where they profit from administrative errors and out-of-network negotiations at the employer's expense. My personal favorite scam is the one where TPAs let suspect billings slide through the cracks just so they can charge a recovery fee for heroically "uncovering" their own mess. Full Article.

[Modern Healthcare] UnitedHealth's Medicare Strategy

A recently released Senate Judiciary report reveals that UnitedHealth Group deployed "aggressive strategies," including the use of artificial intelligence, to inflate patient diagnoses and maximize reimbursements for its Medicare Advantage plans. The investigation suggests that the insurer turned risk adjustment into a revenue-generating business model focused on exploiting coding rules rather than accurate patient care. Given the sheer scale of this AI-powered effort to extract federal funds, labeling these tactics merely "aggressive strategies" is easily the understatement of the century. Full Article

(BenefitsPro) Surge in Catastrophic Health Claims

Lockton's analysis of 2024 employer health plan data reveals a stark rise in catastrophic costs, highlighted by a single patient accruing over $9.1 million in claims and a 47% increase in the likelihood of claims exceeding $2 million since 2022. This surge is largely driven by escalating expenses for medical specialty drugs and cancer care, with average chemotherapy costs nearly tripling per member per month over the last year. Honestly, when you see a single patient racking up over $9 million, you have to wonder if provider billing departments are using the kind of "creative" mob accounting usually reserved for money laundering schemes. Full Article