UnitedHealth uses algorithms to limit mental health care, jeopardizing patient treatment for cost savings.
For years, therapists felt like they were being targeted by UnitedHealth Group, without any apparent reason. Periodically, a representative would call, questioning why a patient had received weekly or twice-weekly sessions for the past six months. After a series of questioning, United would then refuse to cover the patient’s therapy services, leaving the individual to either pay out-of-pocket or forego treatment altogether, forcing them to abruptly terminate their care. It was difficult for clinicians and patients alike to determine why these calls were happening and why coverage was being denied. Therapists were left wondering about the health of their former clients. Around 2016, government investigations began to uncover United’s strategy. The nation’s largest health insurer was using algorithms to identify therapists it deemed were offering “too much” care and patients it considered were receiving “too much” therapy. By the end of 2021, United’s algorithm cost-saving program was declared illegal in three states, but this didn’t stop the company.
A recent ProPublica investigation has revealed that the insurer has still been using these systems, disguised as “cost-control measures,” to limit mental health care and save costs. Through Optum, its mental health subsidiary, United continues to scrutinize what it sees as “overuse” of therapy, flagging any patients who exceed 30 sessions in eight months. According to company documents, these measures could save United $52 million.
This situation underscores a fundamental problem in U.S. health insurance oversight, in general—too much fragmentation. United, one of the ten most profitable companies globally, serves people in every state yet lacks a single regulating authority. Instead, a patchwork of federal and state agencies each oversees only a portion of United’s sprawling network. For example, when California regulators flagged United’s practices in 2018, their corrective measures applied only to marketplace plans based in California. When Massachusetts forced United to make changes in 2020, the order only covered that state. And despite a historic, multimillion-dollar settlement in 2021 against United in a joint action by New York and the U.S. Department of Labor, these restrictions didn’t cover all of United’s insurance plans. Each regulator was essentially limited to addressing United’s practices within its specific jurisdiction.
The lack of comprehensive regulation means that, while individual states might impose limits, United can continue questionable practices elsewhere. ProPublica reviewed internal company documents revealing that United has quietly shifted its focus to Medicaid plans in states without existing restrictions. The insurer now targets patients under its privately contracted Medicaid plans, which cover some of the most vulnerable individuals in the country. Medicaid covers approximately 6 million people under United’s administration, a segment that earned the company $75 billion in revenue last year alone.
United claims compliance with federal laws and maintains that its cost-saving programs help ensure patients receive only “necessary” treatment. However, the approach used to limit therapy sessions is more about financial savings than clinical needs. In fact, many therapy plans involve meeting with clients on a weekly or biweekly basis for at least six months, and oftentimes, much longer. If a patient needs more intensive care, they can easily see a provider much more often than this for a much longer period of time.
Tim Clement of Mental Health America explained that these practices often don’t rely on clinical rationale; they exist primarily as cost-saving mechanisms. Former United employees have echoed these concerns. These employees, who once worked as “care advocates,” the employees responsible for making the calls, shared how they were pressured to question providers’ decisions and limit patient care, even when they felt it wasn’t in patients’ best interests.
Originally, the algorithm United used was known as ALERT, created years ago to flag high-risk patients. However, it soon became a tool for spotting “overuse” of therapy. Any therapist who provided what the algorithm deemed excessive care was flagged. ALERT was triggered when patients had therapy more frequently than the company preferred, like twice a week for six weeks or more than 20 sessions in six months. United applied scrutiny to therapists who worked too many hours, used similar diagnosis codes for multiple clients, or worked outside typical hours, even though many therapists do so to accommodate clients in crisis.
Once flagged, a therapist’s care was reviewed by United’s care advocates, who would typically challenge the provider’s rationale for treatment. These calls often resembled interrogations, with a clear presumption that therapy was unnecessary or excessive. Former employees described the system as overly aggressive and financially driven, with advocates expected to question providers in nearly 20% of cases.
United has rebranded its approach since the onset of ALERT. Now operating under the “Outpatient Care Engagement” cost-saving program. According to internal documents, over 50 care advocates are tasked with evaluating these cases, focusing on plans that remain outside the jurisdiction of earlier sanctions. This continued targeting is particularly concerning for Medicaid patients, who are among the most in need of consistent mental health care. If the cost-saving program is able to continue operating, many individuals could be left without care during times when they need it most.
Sources:
Inside UnitedHealth’s Playbook for Limiting Mental Health Coverage
How Minnesota-based UnitedHealth’s playbook for mental health coverage puts treatment at risk
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