Texas Attorney General Ken Paxton has opened an investigation into UnitedHealth Group over care the insurer is accused of denying Texans. One example in the case is a patient who was told a procedure was approved and then received a large bill after the approval was withdrawn. His office announced the investigation on October 5, and says it has issued civil investigative demands to the company.
No court has ruled on any of this, and the announcement does not include a response from UnitedHealth. What it does describe is a patient who got a letter saying a service was approved, had the service, and then learned the approval no longer counted. Anyone who has a prior-authorization letter in hand, or who has been told no, has a reason to know what the paper trail should look like and how an appeal works.
A prior-authorization approval pulled after the procedure left a patient in Austin with a large bill, according to the Texas attorney general. The Medicare Cost & Coverage Protection Kit sets out the prior-authorization appeal steps for anyone on Medicare who gets a denial.
Get the prior-authorization appeal steps in the Medicare Cost & Coverage Protection Kit →
What the attorney general says
The announcement says reports indicate UnitedHealth, which it calls “United,” has engaged in a number of unlawful practices in administering health insurance benefits and making patient-care decisions. Among the reports is an allegation that United “bribed nursing homes to delay hospitalizing patients who needed medical care.” The office also says United’s coverage determinations may amount to the corporate practice of medicine, in which an insurer overrides a doctor’s judgment and directs a patient’s care.
Paxton’s office says denying care that treating physicians consider medically necessary delays treatment, and that “the longer the delay, the greater the risk that care comes too late.” In his words, “No Texan should be denied medically necessary care, dragged through endless appeals, or stuck with devastating bills” after trusting an insurer’s word.
The attorney general says the civil investigative demands were issued to collect evidence of potential violations of the Texas Deceptive Trade Practices Act and other state laws. That makes this an investigation, not a lawsuit. The announcement gives no dollar figure for the care in question.
The Austin procedure
The one patient story in the announcement involves RedBud Surgery Center in Austin. A Texas patient received a letter from United approving a prior-authorization request for a procedure at the center. After the procedure, United sent a second letter withdrawing the approval, and the patient was left with a large medical bill.
The announcement does not name the patient, give the amount of the bill or say what the procedure was. The case stands in the announcement as an example of what the office says it will look into, and it is the reason a prior-authorization letter is worth keeping.
Appealing a denial in Texas
The Texas Office of Public Insurance Counsel describes the steps for a denied claim. The first is to read the health plan’s documents, or ask the plan or the employer, for the appeal process, which usually requires a form or a letter. An internal appeal generally has to be filed within 180 days of receiving the denial notice, and it should say which denial is being appealed and why it should be reviewed.
Copies matter. The office says to save the Explanation of Benefits forms, copies of everything sent to the plan and notes from any conversation about the appeal. After the internal appeal is used up, some people can ask an independent review organization to look at the decision. When a plan denies a claim as unnecessary, inappropriate, experimental or investigational, it must provide an independent review form. The plan pays for the review and has to follow the decision, which comes within 5 days for emergency treatment and 20 days for other care.
Not every plan is covered. According to the Office of Public Insurance Counsel, Medicare, Medicaid and employer plans governed by the federal ERISA law do not have to take part in the independent review process. The office’s help line is 1-877-611-6742, and the Texas Department of Insurance office that handles independent review answers at 1-866-554-4926.
Filing a complaint with the attorney general
The attorney general’s office accepts consumer complaints through an online portal that asks which of three forms fits: General, Privacy or AI. The form asks for the business’s name and full address, a clear statement of the problem, and details such as transaction dates and amounts, contract and payment information and any steps already taken to fix the issue. The system cannot save a complaint in progress.
The office says to leave out sensitive information such as a date of birth, Social Security number and financial account numbers. Attachments are optional, up to 10 files of 25 megabytes each. Texas law makes complaints open to the public, and a confirmation email carries the complaint number.
Appealing a denial or a withdrawn approval
The documents that matter are the ones that show what the insurer said and when: the approval letter, any later letter withdrawing it, the Explanation of Benefits, the bill, and notes of each call with names and dates. Putting them in date order before starting an appeal makes the sequence clear, and the 180-day appeal window runs from receipt of the denial notice.
Two routes run side by side. The plan’s own appeal process comes first, and the Office of Public Insurance Counsel explains it and takes calls. A complaint to the attorney general goes through the office’s consumer protection division, which says it accepts complaints, files civil cases in the public interest and educates Texans on how to spot scams.
The announcement from Paxton’s office is the place to watch for what comes next. Any lawsuit, settlement or finding would come from that office. UnitedHealth’s side of the story is not part of the October 5 announcement.
A withdrawn approval starts an appeal clock
Texas’s public insurance counsel says an internal appeal generally has 180 days from the denial notice. The Medicare Cost & Coverage Protection Kit puts the steps for fighting a denial in order, with a part called Beat a Denial, for anyone on Medicare who gets a no. The kit runs 15 pages.
Work through a denial with the Medicare Cost & Coverage Protection Kit →
This article was produced with AI assistance and edited for accuracy against the sources linked above.
