Friday, March 27, 2026

The Maryland Insurance Administration fined Cigna $80,000 and ordered the insurer to stop automatically downcoding physician claims — changing submitted billing codes to cheaper ones and pocketing the difference. Cigna's downcoding policy took effect October 2025 and affected an unknown number of its 358,000 Maryland households. The state now requires Cigna to pay doctors within 30 days or provide a specific denial reason.

Septicemia hospitalizations in Massachusetts tripled since 2010, reaching 42,000 in the year ending September 2025. The Boston Globe investigation found both sides deploying AI: hospitals use coding optimization tools to bill the highest defensible severity; insurers use denial algorithms to reject those codes. BCBS Massachusetts posted a $380.5M operating loss last year. Hospitals say they're forced to upcode because insurers deny everything; insurers say hospitals game severity. The patient is nowhere in this equation.

MA plans must publish aggregate PA approval/denial metrics by March 31. First reporting cycle. 72-hour expedited decisions and 7-day standard decisions now enforced since January 1. Plans must also disclose average turnaround times. CMS killed service-level reporting — only contract-level aggregates. The pre-written X thread should be finalized and ready to deploy the moment data drops.

A Minnesota federal judge on March 9 ordered UnitedHealth to hand over internal documents on nH Predict, the AI tool its subsidiary naviHealth uses to manage Medicare Advantage post-acute care claims. Plaintiffs allege nH Predict carries a 90% error rate — nine out of ten denied claims reversed on appeal. UnitedHealth continued using it because only 0.2% of patients ever appeal. UHC's post-acute denial rate jumped from 8.7% in 2019 to 22.7% in 2022 after NaviHealth deployment. The court ordered documents going back to January 2017, including records on whether the AI was designed to override physician judgment.

CEOs from UnitedHealth, CVS, Cigna, Elevance, and Ascendiun testified in back-to-back House hearings in January. When asked whether overturned claim denials negatively affect executive compensation, no CEO raised their hand. CVS CEO David Joyner received $41M in 2024 compensation. UnitedHealth CEO Stephen Hemsley received a $60M one-time equity award. 19% of in-network ACA claims denied. Less than 1% appealed. 44% of appeals succeed.