After UnitedHealthcare denied his surgery, Donald Grant took his 11-page legal and medical appeal straight to UnitedHealth Group CEO Stephen Hemsley — and got his request approved.

Last month, Elizabeth Nicholas wrote in Vanity Fair about being diagnosed with breast cancer at 36 and then watching her insurer refuse to pay for a recommended course of chemotherapy. Her oncologist delivered the news. Nicholas’s response was to email the company’s CEO directly, laying out her case in plain, human terms rather than routing it through the black box of the standard appeals process.

I mentioned her essay briefly in the piece we published recently on artificial intelligence and health insurance denials. Since then, another case landed in my inbox that is worth looking at alongside hers. This patient fought back with an extraordinarily detailed appeal that shows just how sophisticated patients are becoming when an insurer denies critically important care.

You have to write a letter built to break through the corporate bureaucracy

On September 12, I was copied on an email from Donald E. Grant Jr., a 49-year-old industrial-organizational psychologist in Valley Village, California. It was addressed to UnitedHealth Group CEO Stephen Hemsley and copied to more than a dozen other people, including UnitedHealthcare executives, Optum’s chief medical officer, a California state senator, the lieutenant governor’s office, Attorney General Rob Bonta, and two health care reporters. Attached was Grant’s formal appeal, which runs eleven pages and cites the Code of Federal Regulations, ERISA case law and Department of Labor guidance, chapter and verse.

Grant’s situation was — and still is— serious and getting worse. A fall in August 2025 caused the sudden loss of sensation in his legs. Workup found severe congenital cervical stenosis. An in-network surgeon performed a two-level artificial disc replacement in December 2025, but it failed to adequately decompress his spinal cord. By March 2026, imaging showed new myelomalacia — scarring inside the cord itself that wasn’t there before surgery — spreading across four vertebral levels. He now has bilateral foot drop, no sensation in his lower legs, a hand going numb and weak, and new bowel and bladder problems. His surgeon, Dr. Hyun Bae at Cedars-Sinai, is a leading authority on multilevel cervical arthroplasty and its revision — one of the physicians who ran the original FDA trials for the very device implanted in Grant’s neck.

UnitedHealthcare has no in-network surgeon with comparable qualifications, and Grant argues none can safely operate within the window his deteriorating spinal cord allows. The surgery is scheduled for October 14. Everything but the surgeon himself — the hospital, the anesthesia team — is in network. He’s asking UnitedHealthcare to cover Dr. Bae at the in-network rate through a network exception.

What sets Grant’s letter apart isn’t the medicine. It’s the legal architecture around it, and that’s because he had help from Claimable, the AI-assisted appeal service founded by Warris Bokhari. The letter invokes the federal urgent-care claim regulation and its 72-hour decision clock. It demands that the reviewing physician be named, board-certified in the relevant specialty, and walled off from whoever issued the original denial — citing the exact subsection of the claims-procedure regulation that requires it. It requests the complete claim file and designated record set under both ERISA and HIPAA. It puts UnitedHealthcare on notice to preserve every internal record connected to the claim. And it names, as a co-recipient with real leverage, David Ellison — chairman and CEO of Paramount Skydance, the company whose self-funded plan is actually paying these claims, and therefore the ERISA plan administrator and fiduciary who can lean on UnitedHealthcare from above.

There’s also a section I want to draw special attention to, because it’s the clearest expression I’ve seen from a patient of a concern I’ve been raising for months: Grant explicitly demands that no algorithm, predictive model, or automated tool be used at any stage of deciding his appeal, and he wants written confirmation of that in the response. He backs the demand with a tight legal and factual history — ProPublica’s reporting on Cigna’s PXDX system, the nH Predict litigation against UnitedHealth, the Senate Permanent Subcommittee on Investigations’ 2024 report on Medicare Advantage denials, and California’s Physicians Make Decisions Act. His argument is that a federal regulation most patients have never heard of already requires what California’s algorithm-ban requires: a qualified human being in the relevant specialty, not a model trained on aggregate outcomes, deciding whether his particular spinal cord can wait.

The strategy worked. Grant told me this week that UnitedHealthcare has now approved both Dr. Bae and the procedure at the in-network rate, clearing the way for the October 14 surgery. And Grant was careful to give the insurer credit for how it handled the process once his appeal was underway. He said UnitedHealthcare employees were responsive and patient in helping him understand the approval and what he would owe out-of-pocket at the in-network rate.

“I realize this is not always the case,” Grant wrote, “but this time it worked out well.”

That’s an important part of this story too. The point isn’t that every appeal ends badly, or that an insurer can’t respond appropriately when a patient pushes back. Grant got the result he was asking for. But it took an eleven-page appeal, detailed medical and legal arguments, and an email that put executives, public officials and reporters on notice to get there. His case shows that patients can successfully challenge these decisions. It also raises a harder question: How many patients would have known how to mount the same fight?

The strategy patients weren’t supposed to have

I’ve been telling patients for years to do exactly what Nicholas and Grant did: If a denial threatens your life or your ability to function, don’t just work the internal appeals queue quietly. Go to the top. Email the CEO. Loop in the plan sponsor if you’re on an employer plan. Contact your state insurance commissioner or attorney general. Call your legislators. Talk to a reporter. Be the squeaky wheel. Insurers built the appeals system to be slow, opaque, and easy to lose interest in. They know that discourages patients to give up. Do not give up or even go through the normal bureaucratic nonsense if time is of the essence.

The nation’s largest health insurer says it is eliminating prior authorization requirements for 1,700 medical codes. Look under the hood and the announcement is considerably less impressive.

Nicholas didn’t have Grant’s legal scaffolding. She had her own voice and the reach of a national magazine. Grant has a documented clinical emergency, a sympathetic and well-known plan sponsor CEO, a growing list of public officials on notice, and — importantly — professional help translating his situation into the language ERISA regulators and general counsel offices actually respond to.

There’s a less comfortable layer here too. Grant had to do all of this — hire or enlist expert help, cite the C.F.R., demand a litigation hold on internal records — just to get the process ERISA already promises every plan member by law: a full and fair review, decided by someone qualified, free of algorithmic shortcuts. Most people denied a surgery their doctor says they need don’t know these regulations exist, let alone have the resources or stamina to invoke them. That gap is the real story underneath both of these cases. The system shouldn’t require this level of sophistication to work as designed. It just doesn’t work reliably without it.

II’ll be watching to see whether Grant actually gets his laminoplasty on October 14 with Dr. Bae in the room.

https://healthcareuncovered.substack.com/p/the-wall-street-chameleon-big-insurance

In Episode 1 of the HEALTH CARE un-covered Show, we examine what may be an inflection point in the health insurance reform debate. Plus, we’re joined by pollster Madeline Conway of Impact Research.

The volume of claims is treated as proof of misconduct, despite the fact that the statute imposes no limit on IDR submissions and explicitly allows for repeated use when payment disputes continue. Further, insurers base this claim on estimates of IDR submissions that were deeply flawed, forecasting nationwide utilization on the experience of one state.

The message is unmistakable: providers are not accused of breaking the NSA, but rather of utilizing it too effectively. For instance, insurers claim that providers submitted “thousands” of IDR disputes, including nearly “200 overlapping proceedings for the same services” across both the federal and state IDR systems, and batched an average of 66 separate items or services into a single IDR filing: Insurers describe these statistics as “overwhelming,” despite the fact that each dispute is linked to a corresponding payment denial or gross underpayment.

Recasting Physician Disputes as “Fraud”

Each lawsuit hones in on physician NSA disputes and castigates them as some kind of “fraud” or “abuse.” The HaloMD lawsuits are a prime example of the insurer taking an NSA dispute, challenging the disputes eligibility for arbitration and then recasting it as “fraud.” What these lawsuits notably fail to recognize is that the outcomes of IDR are determined by independent arbitrators, called certified IDR entities (IDREs), not by the providers themselves.

According to CMS’s public-use files, 82% of 2024 disputes and 80% of 2025 disputes were found eligible for arbitration. This is orders of magnitude greater than what the government had estimated. What these numbers tell us is that the problem with the volume of disputes is not a conspiracy by doctors to abuse this system, but systemic underpayment by insurers, as we have reported.

In the lawsuits, insurers concede that it was the arbitrators, not the providers, who rendered the final awards in these disputes. Insurers also consistently and publicly voice their concerns that NSA awards surpass the Qualifying Payment Amount (QPA), often describing results that are ‘multiples’ of the median in-network rates or even exceeding billed charges. Insurers assert that IDR awards are excessive, “citing CMS data showing that they are on average slightly over 300% of the QPA” of the QPA.

However, a recent analysis shows that the reported QPAs consistently underestimate the actual median in-network rates, with an average discrepancy of 290% in cases where such discrepancies are present. A pervasive problem reported by providers and evident in the public-use files shows thousands of initial offers for payment that amount to less than a dollar. In one documented case involving high-acuity emergency care, the insurer calculated the QPA at $0.01. The arbitrator ultimately awarded $1,196. The gap was not evidence of an inflated charge; it was evidence that the benchmark itself was flawed.

This underestimation is attributed to calculations controlled by insurers, insufficient oversight, and the omission of market factors that Congress mandated arbitrators to consider.

Simply disagreeing with an IDRE’s assessment does not equate to fraud. Rather than modifying payment practices, enhancing negotiations, or pursuing legislative clarity, insurers have opted for litigation as a tool to crush providers while claiming unfavorable arbitration results as evidence that the system is being “manipulated.” They are both arsonists and firefighters.

The Litigation Boa Constrictor

Across jurisdictions, insurers clearly claim that defendants engaged in “coordinated enterprises,” “strategic partnerships,” or “associations-in-fact,” alleging RICO violations founded on the concurrent use of IDR, common billing vendors, and simultaneous filings, even though there is no statutory restriction against coordinated IDR usage or shared administrative frameworks.

The recurring themes in these filings are hard to overlook. In the last 12 months, there have been 11 lawsuits targeting use of the No Surprises Act, four alleging RICO violations and five seeking treble damages.

So far, this coordinated lawfare effort includes the following suits:

• Blue Cross Blue Shield of Texas v. HaloMD et al. (E.D. Tex., Aug. 2025)
• Blue Cross Blue Shield of Texas v. Zotec Partners, LLC (E.D. Tex., Dec. 2025)
• Anthem Health Plans of Virginia v. AGS Health / SCP Health et al. (W.D. Va., Nov. 2025)
• Community Insurance Co. (Anthem Ohio) v. HaloMD et al. (S.D. Ohio, June 2025)
• Blue Cross Blue Shield Healthcare Plan of Georgia v. HaloMD et al. (N.D. Ga., May 2025)
• Anthem Blue Cross (CA) v. HaloMD et al. (C.D. Cal., July 2025)
• Anthem Blue Cross (CA) v. Prime Healthcare entities (C.D. Cal., Jan. 2026)
• UnitedHealthcare of Pennsylvania, Inc. v. NorthStar Anesthesia of Pennsylvania, LLC (E.D. Pa., Dec. 2025)
• UnitedHealthcare Insurance Co. v. Maui Emergency Care Physicians, LLC (D. Haw., Jan. 2026)
• United Healthcare Services, Inc. v. Concord Company of Tennessee, PLLC (W.D. Ky., Jan. 2026)
• UnitedHealthcare Ins. Co. v. Radiology Partners, LLC (D. Ariz, Aug. 2025)

These prosecutions follow a distinct pattern of allegations: strategic batching, simultaneous filings, excessive offers, false statements, and an alleged conspiracy to take advantage of IDR. Even when the factual circumstances vary, the narrative remains the same. This consistency indicates not an independent discovery of wrongdoing, but a calculated strategy.

The targets of these lawsuits represent the full spectrum of organizations utilizing the NSA. From revenue cycle management (HaloMD) to large physician staffing organization (SCP) to small physician practice management group (Concord Company), insurers are constricting the entire provider community hoping to alter the NSA through legal outcomes.

Litigation as Press Release

The litigation involving Prime Healthcare highlights this strategy particularly well. In this case, insurers openly admit that hospitals are utilizing IDR instead of balance billing patients, precisely what Congress intended, yet they still label this behavior as abusive because it led to payments that were higher than what insurers were prepared to offer. Lawful reliance on IDR is recast in this complaint as “extractive,” “indiscriminate,” or “profitable abuse,” as if the issue lies not with insurer underpayment but with the presence of an independent referee who has the authority to disagree with them.

The impact on the real world is far from just a theory. These lawsuits aim for treble damages, annulment of arbitration awards, and injunctions intended to completely deny providers future access to IDR. The message from insurers is clear: engage in the IDR process established by Congress, and you will face consequences. Providers who utilize IDR are not seen as legitimate participants in a federal program; instead, they are viewed as targets, labeled as racketeers, pulled into costly litigation, and compelled to defend their right to contest underpayment. These lawsuits serve as a deterrent and act as a warning to discourage providers from engaging in IDR by making the costs of participation excessively burdensome.

Breaking the NSA Balance

No lawsuit will have more far reaching consequences for physicians than UnitedHealthcare v NorthStar Anesthesia (the insurer has filed five similar lawsuits). While this suit follows the usual script of allegations it aims for something more pernicious than unflattering headlines: declaratory judgment of fraud for ineligible disputes. The eligibility of an NSA dispute rests solely with CMS and the independent arbitrator – they are administrative. Physicians have repeatedly shown that insurers withhold critical information needed to determine a claim’s eligibility, the result being that occasionally physicians will dispute a claim that is ineligible for arbitration. According to CMS, with more than 80% of claims sent to arbitration being determined as eligible, these mistakes are the exception, not the rule.

However, if UnitedHealthcare is granted the relief it seeks, insurers will be able to challenge dispute eligibility in court, outside of arbitration, and receive direct judgments of “fraud” against physicians who have filed ineligible claims. A declaratory judgment of fraud would not simply reverse a payment. It would create precedent allowing insurers to relitigate administrative eligibility decisions in federal court and seek damages for disputes that arbitrators have already accepted into the federal process. This elevates an administrative error into reputational and legal risk that no physician practice could withstand.

The NSA’s public policy goal of removing patients from billing disputes, was buttressed by leveling the playing field between physician practices and insurance behemoths. The sweeping effects of this case will fundamentally alter the scales in favor of insurers and not just chill, but shut out doctors from obtaining fair reimbursement.

Shifting the balance of power

This situation should alarm policymakers as well as doctors and their patients. It embodies the risk of extended, multi-faceted litigation initiated by trillion-dollar insurance conglomerates targeting individual physicians, small practices, and safety-net hospitals that do not possess equivalent resources.

This pressure does not safeguard patients. Instead, it discourages providers from contesting underpayment, shifts the balance of power firmly back to insurers, and dissuades the use of the very system intended to resolve disputes and protect patients. In the meantime, insurers leverage extensive financial resources to maintain coordinated litigation efforts while depicting providers, especially those offering emergency care, as wrongdoers for employing the only legal remedy available.

Ultimately, these legal actions are not aimed at preventing misconduct. Instead, they focus on altering market structure. By transforming the routine application of IDR into a significant litigation risk, insurers are indicating that independent providers who challenge payment terms will face penalties instead of negotiations.

The foreseeable outcome is the consolidation of providers: small practices, emergency physician groups, and safety-net hospitals will be compelled to sell, affiliate, or close rather than endure the costs and uncertainties associated with defending against repeated federal lawsuits. As we’ve reported, Optum now employs more than 90,000 clinicians. Simultaneously, this approach accelerates the vertical integration of insurers, directing care toward entities that are either owned or aligned with insurers, which are shielded from payment disputes and arbitration. Within this context, the courts do not serve as a venue for resolving conflicts; they function as a mechanism for enforcing market discipline. This undermines the fundamental objective of the No Surprises Act to balance bargaining power and, in turn, reinforces insurer dominance over pricing, networks, and access to care.

A law meant to protect patients and equalize bargaining power is being weaponized by insurers to suppress those who question insurer payment practices and, in doing so, to silence the underdog.