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NEW YORK CITY — The police search continues in New York City for the man who gunned down the CEO of UnitedHealthcare on Wednesday outside a hotel where he was to deliver a conference speech. On Thursday, officials released two photos of the man suspected of killing Brian Thompson, who has thus far eluded them.
Investigators worked to piece together more of the timeline of the gunman's whereabouts before the shooting, examine security camera footage and even test a discarded water bottle and protein bar wrapper in a hunt for his DNA, the Associated Press reported Friday.
Bullet casings collected after Thompson was shot appeared to be inscribed with words including "deny" and "defend," leading to speculation of a possible motive for the killing.
UnitedHealthcare and other large insurers have received criticism and recent Congressional scrutiny, including in Utah, for ways in which they may try to avoid paying for patient care, including denying benefits and then defending their decision.
Reports said the words on the casings also included "depose," while a "delay" was written on a live round that was ejected when the shooter appeared to be clearing a jam.
As Corey Kilgannon of The New York Times wrote, "While they have multiple meanings, the words 'delay' and 'deny' could be a reference to the ways insurance companies seek to fend off claims.
A 2010 book on the topic, 'Delay, Deny, Defend,' argues that health insurers' claims departments try to increase their profits by not honoring the terms of insurance policies, shortchanging policyholders."
The shell casings have prompted discussion, including numerous references to a "scathing" report that the U.S. Senate Permanent Subcommittee on Investigations issued in October that looked particularly at how Medicare Advantage patients have been denied access to post-acute care after they suffered strokes, falls and other serious medical incidents.
The suspect has not been captured and the motive isn't known, but someone close to the investigation told The Washington Post that officials were looking into whether insurance company business practices were related to the shooting, given the words on the bullet casings.
Here's what Senate investigators found when they looked into the Medicare Advantage programs offered by the big three companies — United Healthcare, CVS and Humana — that have collectively enrolled nearly 60% of Medicare Advantage participants.
Artificial intelligence becomes insurer tool
Medicare Advantage is an alternative to traditional Medicare for those who qualify for the government-sponsored health insurance program that serves older adults and people with disabilities. While traditional Medicare pays for covered services at its set rates in approved facilities, Medicare Advantage plans may offer additional covered services, such as dental or vision, and act more as a health maintenance organization, managing care.
The details vary based on each plan's design, coverage and the company offering it. But Advantage plans increasingly rely on preauthorization (about 99% of enrollees were in plans requiring some preauthorization by 2023, per the Kaiser Family Foundation).
The insurance companies have said that preauthorization has been important to allow them to grow and be profitable so they can provide their services.
The Senate report noted significant growth in such denials of preauthorization for services in the past few years.
It also highlighted the way that "predictive technology" — artificial intelligence — could be superseding human judgment when it comes to medical needs and the treatments provided in Medicare Advantage. Calling the findings "troubling," the report said that it appears the companies "are intentionally targeting a costly but critical area of medicine — substituting judgment about medical necessity with a calculation about financial gain."
The authors urge the Centers for Medicare and Medicaid Services to collect data and expand regulations to make sure predictive tech doesn't have "undue influence on human reviewers."
The report concluded that:
- UnitedHealthcare, Humana and CVS used prior authorization to target costly but critical post-acute care.
- United Healthcare's denial rate for prior authorization requests for post-acute care significantly increased at the same time the company was launching initiatives to automate the process.
- CVS knew prior authorization denials generated huge savings and subjected more and more post-acute care requests to the process. As a side note, the report said "CVS data modeling revealed how 'mistake' approvals of post-acute care requests threatened profitability."
- Humana's denial rate at long-term acute care hospitals jumped significantly after prior authorization training sessions emphasized denials. That included creating templates that would create language that would be upheld on appeal, the report said.
Per the report, "... It is insurers who are using prior authorization to protect billions in profits while forcing vulnerable patients into impossible choices."
Impact on patients
Artificial intelligence has helped use of prior authorizations to flourish.
A Statnews investigation found in 2023 that naviHealth, owned by UnitedHealthcare's parent company, United Health Group and used by multiple Medicare Advantage insurers, was letting artificial intelligence help decide how long patients could stay at different inpatient facilities. Sometimes artificial intelligence contributed to decisions on whether patients could even be admitted.
In 2022, when the Office of the Inspector General looked at a sample of denied prior authorization requests and payments by Medicare Advantage insurers, based on 2019 data, investigators found 13% of the denied requests should have been approved, the report said. If that rate held true across the board that year, "it would mean that Medicare Advantage insurers would have rejected 84,812 prior authorization requests that met Medicare coverage rules and should never have been denied in the first place."
In a survey cited by the subcommittee, nearly 8 in 10 doctors said that prior authorization "sometimes led to abandoned treatment and that 24% said that the practice had led to a 'serious adverse event' for patients in their care," the report authors wrote. "Media reports on hospital and provider groups that have stopped accepting Medicare Advantage patients cite 'excessive prior authorization denial rates,' along with an allegedly slow pace of Medicare Advantage insurer reimbursement for claims that are approved, as the primary reason."
The Centers for Medicare and Medicaid Services has issued new regulations regarding the use of prior authorization, including making clear that prior authorization policies for coordinated care plans are only to be used to "confirm the presence of diagnoses or other medical criteria" or to make sure that services are "medically necessary," according to the report, which said it's too soon to know if the new rules will reduce delays or denials of care. The report also noted claims by some companies that the changes could reduce future growth and profitability.
