Summary
- Texas is investigating two medical insurance companies over alleged delays and denials of urgent medically necessary care.
- When someone controls access to medical care, who answers for the consequences?
- Our insurance system requires honesty, transparency, and accountability.
At 20, I discovered a half-centimeter thyroid nodule. It was cancer. I was told it was slow-growing, that spread at that size was nearly impossible, and that I could wait years before surgery.
I successfully pushed for surgery anyway. My cancer had already spread to three lymph nodes, which were removed.
When my symptoms persisted, and my bloodwork remained elevated, I requested further testing. But I did not meet my insurer’s criteria, so my doctors, who had to practice within those rules, would not order it.
About a year later, I finally qualified for another biopsy. The cancer was still there. A second surgery removed the rest of my thyroid and 32 lymph nodes, eight of which contained cancer.
What if I had waited five years? How much more would delayed treatment have cost, in money and pain? Being told to wait carries medical risks, not just administrative consequences.
That is why two investigations announced by Texas Attorney General Ken Paxton caught my attention. On Sept. 28, he opened an investigation into Blue Cross Blue Shield of Texas over alleged delays and denials of urgent, medically necessary care, including a newborn’s delayed transfer for urgent treatment. A week later, he opened another into UnitedHealth Group, citing an Austin patient whose procedure was allegedly approved, performed, and then retroactively denied.
Both investigations raise the same question: When someone controls access to medical care, who answers for the consequences?
Prior authorization is only one way insurers control care. Step therapy, medical reviews, formularies, and networks also determine which treatments patients can access. Intended to prevent waste, these mechanisms have become barriers when insurers’ financial interests conflict with medical evidence and patients’ savings. When a corrupt financial incentive overrides medical evidence, patients bear the consequences.
Texas lawmakers saw what this looks like for patients and physicians at the House hearing on Women’s health. Shelagh Larson, a nurse practitioner, testified about a breast cancer patient suffering severe hot flashes. Despite estrogen generally not being recommended for breast cancer survivors, Larson said that the insurer asked whether the patient had tried it, then demanded trials of antidepressants and anti-seizure drugs before covering an FDA-approved nonhormonal treatment.
Larson eventually reached a “peer-to-peer” reviewer, where a physician evaluates another clinician’s treatment recommendation. But her reviewer was a podiatrist, a foot specialist, rather than a physician with expertise in women’s health or menopause care. When she finally spoke with a gynecologist, approval was almost immediate.
Eight weeks of waiting for three seconds of medicine.
Texas law already requires a Texas-licensed physician in the same or similar specialty for certain peer-to-peer reviews. When Chairwoman Pierson asked whether insurers followed that requirement, the industry representative’s answer was a hesitant, “I really hope we’re following.”
Dr. Heidi Russell, a pediatric oncologist with severe osteoporosis, described how step therapy can require patients to try an insurer-preferred drug and show it is ineffective before receiving prescribed bone-building treatment. For osteoporosis patients, waiting for treatment failure can mean a broken hip or collapsed vertebra. As Russell put it, “these corporations are practicing medicine without a license.”
The industry representative also explained that physician reviewers determine whether prescribed treatments meet medical necessity standards and scientific evidence. That is a medical judgment.
Insurers and employers choose which benefits to offer. But once a plan promises medically necessary treatment, deciding whether a patient qualifies requires clinical judgment. Calling it a coverage decision does not erase its medical consequences.
Texas law already recognizes this distinction. The Insurance Code defines adverse determinations in terms of medical necessity or appropriateness, requires denial notices to identify their clinical basis, and prohibits automated systems from making those determinations.
Yet oversight focuses on process and complaints. When Pierson questioned whether insurers followed the law, the industry’s representative cited a lack of complaints. As Pierson noted, that logic expects patients and doctors to take another step after weeks of fighting for care.
The Texas Department of Insurance told lawmakers it regulates plans covering only about 22% of Texans. Even within its jurisdiction, TDI lacks comprehensive claims and denial data and does not evaluate underlying clinical judgments during examinations.
Insurers’ own reports reveal why that matters. In 2025, Ambetter from Superior HealthPlan reversed 2,129 of 3,439 appealed denials, approximately 62%. Yet only about 5% of its 71,824 standard denials were appealed. When so many decisions change upon appeal, and so few patients appeal, how meaningful is a lack of complaints?
A reviewer can reject a treating physician’s judgment while regulators examine the process surrounding that rejection. Responsibility should follow control, and that starts with two reforms.
First, honesty and transparency. Both attorney general investigations invoked the Texas Deceptive Trade Practices Act. Healthcare intermediaries should be held accountable for deceptive conduct, undisclosed financial incentives, and misrepresentations about medical reviews. Patients and employers deserve to know who made decisions, what evidence supported them, and whether financial interests influenced them.
Second, professional accountability. When a licensed clinician evaluates a patient’s records and determines whether a prescribed treatment is clinically appropriate, that judgment should meet the same professional standards and Texas Medical Board oversight as the treating physician’s judgment.
Tennessee took a step in this direction when it passed a law recognizing clinical-appropriateness determinations as the practice of medicine. A medical license should mean the same thing on both sides of the phone call.
Whether it’s called prior authorization, step therapy, or a coverage determination, these are medical decisions that can cause harm to Texans, medically and financially. Texans should not need an attorney general’s subpoena to find out who made the decision or why. If a corporation has the power to control medical care, it should be responsible for how it exercises that power.
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