Two years ago, Robby Martin got an unsettling call from his father, Jackie. The 82-year-old told his son that a representative of the insurance giant UnitedHealth Group had barged into his nursing home room at 2.30 in the morning, announcing that he was going to be checked out at the end of the week.Jackie Martin – who had been getting rehab at the nursing home after suffering a back fracture – still could not take more than a few steps without being out of breath.But Jackie’s care there, which had started two weeks earlier, was eating into UnitedHealth’s bottom line.The retired paper plant foreman was enrolled in UnitedHealth’s Medicare Advantage program, a federal privatization initiative that offers insurers a lump sum to cover services comparable to those under traditional Medicare. But the program’s pay structure means that the more care insurers deny, the more in taxpayer dollars they get to keep for themselves. Now, UnitedHealth was pushing to terminate the 82-year-old’s rehab coverage.Jackie and his son appealed UnitedHealth’s decision and won. But the corporate giant issued another coverage termination letter the following week, then another one the week after that.Martin was a quiet man who didn’t like conflict. The repeated denials left him exhausted.“We talked and he said, ‘You know, I’m tired of this process every week. Let me just go home and see how I do,’” Robby recalled.Soon after returning home, Jackie told his family he was no longer getting better and needed to find another care option. The next day – five days after UnitedHealth had cut off his nursing home coverage – he died alone in his bathroom.Send us a tipIf you are a current or former United Healthcare or Optum employee and have information you’d like to share securely with the Guardian about nursing home care, please use a non-work device to call or text investigative reporter George Joseph via the Signal messaging app at 929-486-4865.Jackie’s battle with UnitedHealth during the final days of his life is now part of a lawsuit accusing the healthcare conglomerate of wrongfully denying elderly patients care owed to them under Medicare Advantage. His son Robby, who represents his late father’s estate, is now speaking publicly about his family’s experience with UnitedHealth for the first time.“They were just cutting him off because they could cut him off and reduce their expense,” Robby Martin said in an interview. “It’s all a money game to them.”Robby joined the ongoing suit last year, and is one of nine named plaintiffs, led by the Clarkson Law Firm, suing UnitedHealth in US district court in Minnesota.“There has to be some type of moral side to you that says, ‘This needs to be stopped,’” Robby Martin said. “And there needs to be a team of people that stop it.”View image in fullscreenUnitedHealth Group and two of its subsidiaries did not respond to questions about the specific allegations made by Martin.A spokesperson for Optum, one of UnitedHealth’s subsidiaries, said she could not discuss Martin’s case without a waiver releasing the company from federal health information protections. But in a statement, Optum said its “number one priority is ensuring patients receive the care they need”.“We believe this lawsuit has no merit and should be dismissed, as we have asked the court to do,” the statement declared, arguing that the company’s coverage decisions “are made by medical directors in accordance with Medicare coverage criteria for Medicare Advantage Plans”.Martin’s struggle to access care after a hospital visit is not a rare occurrence for older people enrolled in UnitedHealth’s Medicare Advantage program.In recent years, UnitedHealth has ramped up its efforts to deny care for older patients following strokes, falls and injuries that require rehab, according to an October 2024 investigation by the US Senate permanent subcommittee on investigations. The federal inquiry found that UnitedHealth’s prior authorization denial rate for post-acute care for older people on Medicare Advantage shot up from 8.7% in 2019 to 22.7% in 2022. For Medicare Advantage seniors seeking post-acute care in nursing homes specifically, UnitedHealth’s denial rate jumped up dramatically during that period, from 1.4% to 12.6%, amounting to more than 34,000 denials.In a statement, the spokesperson for UnitedHealth’s subsidiary said the Senate committee investigation “mischaracterizes” Medicare Advantage and the company’s clinical practices while ignoring federal criteria “demanding greater scrutiny around post-acute care”.The corporate spokesperson also added that the company “ultimately” pays “98% of all claims” it receives, when they are submitted in “a timely manner with complete, non-duplicate information”.UnitedHealth’s past coverage denials caught renewed attention after the December killing of Brian Thompson, a top executive who helped establish one of its subsidiaries as the dominant player in the Medicare Advantage market. Weeks before Thompson’s killing, Biden administration officials at the Centers for Medicare and Medicaid Services (CMS) proposed new rules to crack down on what it described as the “inappropriate” use of prior authorization by Medicare Advantage insurers. But it is unclear how eager the Trump administration and the Republican Congress will be to regulate insurers.In public statements, Trump’s pick to head CMS, Dr Mehmet Oz, and Republican policy leaders associated with the Heritage Foundation’s Project 2025 have shown more interest in expanding Medicare Advantage than in curbing coverage denials under the program.Republican senator Ron Johnson of Wisconsin, the new chair of the Senate’s permanent subcommittee on investigations, did not respond to requests for comment about whether he planned to have his committee continue to investigate United Healthcare and other Medicare Advantage insurers.In a statement, the Democratic senator Richard Blumenthal, the investigations committee’s former chair, said older Americans like Jackie Martin “should receive the care they need” without delays or denials.“For Jackie, his family, and the countless other Medicare Advantage enrollees, we must fight denials of post-acute care,” Blumenthal said. “I will continue to speak out and hold private insurers accountable for putting profits over people.”The processBefore he suffered a fall on the hardwood floor of his kitchen that left him with a back fracture, Jackie Martin walked two to three miles a day and ran on the treadmill at his local Y in Kingsport, Tennessee.Jackie’s subsequent recovery in the nursing home was slow, but he was making progress. So when Robby heard his father’s rehab coverage was being cut off, he started calling everyone he could.First, Robby called the employee of the UnitedHealth subsidiary, NaviHealth, who had barged into his father’s nursing home room at 2.30am.“She said, ‘Well, at NaviHealth, we have a procedure in place where we issue these weekly discharge notices automatically in our system,’” he recalled.Next, Robby said, he called a social worker at the nursing home.View image in fullscreen“He said, ‘Robby … the last six months here NaviHealth has been kicking out all my patients before they’re ready for self-care,’” he recalled the social worker saying. (The social worker did not respond to requests for comment for this story.)After that, Robby arranged a conference call with a manager from the UnitedHealth subsidiary, who said the notices would keep coming every week, Robby recalls.“This is our process and this is what we do,” he recalls her saying. (The manager declined to comment for this story.)Robby even tried the main number at UnitedHealth, but he couldn’t get anyone to help.“I realized it was a kinda circular thing, where I could not get anything done with anybody … ,” he said. “It’s the most frustrating thing that you ever go through. You feel powerless.”Robby and Jackie had successfully appealed UnitedHealth’s first two denial letters. But the week after the conference call with the manager, UnitedHealth sent Martin a third coverage termination letter. The father and son decided to stop appealing.The lawsuit alleges that these repeat coverage denials were driven by a secret AI algorithm “without any consideration” for Jackie’s “current condition”. UnitedHealth says that algorithm is used to inform providers about care a patient may need, not “to make coverage determinations”.Out of breathOn 19 May 2023, Jackie returned home from the rehab facility to the split foyer house he had raised Robby in. He could get out of bed on his own. But when he tried to walk more than five steps, he found himself out of breath.Three days after going home, the retired foreman told his children he was no longer improving.The next day, Jackie told his daughter he wasn’t feeling well, but there was no nurse to check on him. Hours later, he got up to go to the bathroom. There, his heart gave way.View image in fullscreenFor the next six months, Robby said, he did not think much about UnitedHealth as he grieved. Eventually, a thought kept resurfacing: he had followed the rules. He had appealed, won and appealed again on behalf of his father. He had elevated the issue to corporate, and still the company kept denying his father coverage.Robby searched online for any lawsuits against UnitedHealth’s subsidiary. He found that two families had already taken the conglomerate to court for cutting off their loved ones’ rehab coverage. He decided to join them.Robby says he hopes the litigation will change UnitedHealth’s coverage denial practices.“You know, the small person really doesn’t matter to them. They’re a multibillion-dollar company … ,” he said. “Plus, they also know that these patients that are 80 years old, that it doesn’t matter if they die.”Attorneys representing UnitedHealth Group and its subsidiaries in the case did not respond to requests for comment. In legal filings, the company’s counsel has sought to dismiss the lawsuit, arguing that the plaintiffs have “failed to exhaust” the federally regulated appeals process for challenging coverage decisions.In a statement, Glenn Danas, one of Martin’s lawyers and a partner at the Clarkson Law Firm, said: “It’s clear that United has no intent to act in the best interest – and best health – of the people they insure.”The Minnesota US district court judge John R Tunheim has not yet issued a ruling on UnitedHealth’s motion to dismiss the lawsuit, which could come as soon as the end of this month. More
