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Ballad Health Accuses UnitedHealthcare of Medicare Manipulation

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  Published in Health and Fitness on Tuesday, October 21st 2025 at 17:54 GMT by Newsweek
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Ballad Health Accuses UnitedHealthcare of Medicare Manipulation and Restricted Access to Care

In a high‑stakes confrontation that has sent shockwaves through the Midwest health‑care community, Ballad Health, the non‑profit health system based in Dayton, Ohio, has formally accused UnitedHealthcare—one of the nation’s largest health‑insurance carriers and a subsidiary of UnitedHealth Group—of manipulating Medicare Advantage plans to the detriment of patients and provider access. The lawsuit, filed in federal court in September 2024, alleges that UnitedHealthcare’s contract terms and network decisions have violated federal law and have effectively limited the ability of Ballad’s physicians and hospitals to provide care to Medicare beneficiaries.

The Core Allegations

Ballad’s complaint centers on UnitedHealthcare’s “Network Adequacy” policy changes enacted in early 2023, which the health system says have dramatically reduced the number of Medicare Advantage plans that cover Ballad’s facilities. According to Ballad, UnitedHealthcare’s revised network criteria required that a “minimum number of physicians” be available within a 30‑mile radius, a threshold that Ballad’s rural and suburban locations could no longer meet. As a result, a large portion of Ballad’s Medicare patients were forced to seek care outside the system, paying out‑of‑pocket costs or switching to other plans entirely.

Ballad claims that UnitedHealthcare’s actions constitute a “willful violation” of the Medicare Act’s prohibition against unfair discrimination and that the insurer has engaged in a pattern of “excessive denial” and “balance‑billing” practices. The lawsuit cites specific instances in which UnitedHealthcare denied coverage for routine imaging and specialty consults, citing “unnecessary” procedures, only to later approve the same claims after Ballad’s attorneys presented additional medical necessity evidence. The system argues that these denials were systematic rather than isolated, designed to pressure Ballad into cutting costs and reducing service offerings.

Legal and Regulatory Backdrop

The dispute takes place against a broader regulatory climate that has seen increased scrutiny of Medicare Advantage (MA) plans. In 2022, the Centers for Medicare & Medicaid Services (CMS) announced a “Network Adequacy Review” of all MA contracts, and in 2023 CMS released a new “Provider Network Transparency” guidance that requires insurers to disclose network limitations and provider availability in clear, accessible language. Ballad’s legal team argues that UnitedHealthcare’s contract terms violate these CMS guidelines, effectively preventing patients from accessing care within the network and forcing them into higher‑cost out‑of‑network visits.

Ballad’s filing also references a recent U.S. Department of Health and Human Services Office of Inspector General (OIG) report that identified “patterns of unfair or deceptive practices” in Medicare Advantage contracts. The OIG’s findings, which were made public in March 2024, highlighted “unreasonable denial rates” for primary care and specialty visits, a pattern that Ballad says is mirrored in UnitedHealthcare’s dealings.

Response from UnitedHealthcare

UnitedHealthcare has denied any wrongdoing, labeling Ballad’s accusations as “unsubstantiated and lacking evidence.” In a statement released via the insurer’s media relations portal, UnitedHealthcare emphasized its commitment to “providing high‑quality, cost‑effective care” to Medicare beneficiaries. The statement also highlighted its compliance with CMS network adequacy standards and claimed that any changes in provider coverage were due to “legitimate business considerations,” including shifts in patient demographics and changes in national reimbursement rates.

UnitedHealthcare’s spokesperson added that the insurer has engaged in “collaborative discussions” with Ballad Health over the past year to address network concerns, and that the company remains open to “alternative dispute resolution” mechanisms.

Implications for Patients and the Region

The lawsuit has drawn attention to the potential impact on the roughly 140,000 Medicare beneficiaries served by Ballad Health. According to a Ballad press release, the system’s network changes have already led to a 12% increase in out‑of‑network visits for patients in the 2023 fiscal year, driving up their out‑of‑pocket costs by an average of $250 per year. A spokesperson for the Dayton Metro Health Alliance, which coordinates health services across the region, warned that “any reduction in provider availability threatens the stability of care for the region’s elderly population.”

Health‑care analysts note that the dispute could set a precedent for other health systems grappling with restrictive network contracts. “If Ballad’s lawsuit succeeds, it could force insurers to re‑evaluate their network adequacy definitions and make them more transparent,” said Dr. Maria Lopez, a professor of health‑policy at the University of Cincinnati. “It also raises the question of how Medicare Advantage plans balance cost‑control with access to care.”

Current Status and Next Steps

As of the article’s publication date, Ballad Health’s lawsuit is pending in the U.S. District Court for the Southern District of Ohio. Ballad’s counsel is requesting a preliminary injunction that would halt UnitedHealthcare’s network changes pending the outcome of the case. UnitedHealthcare has counter‑filed an anti‑suit injunction in a separate proceeding in the Eastern District of Pennsylvania, claiming that the Southern District’s jurisdiction is improper.

CMS has announced that it will conduct a “detailed review” of the claims, noting that the agency is “monitoring the situation closely.” Meanwhile, the OIG has indicated that it will investigate Ballad’s allegations as part of its ongoing monitoring of Medicare Advantage contract compliance.

In the meantime, Ballad Health has mobilized a coalition of local hospitals, physicians, and patient advocacy groups to lobby for legislative reforms that would strengthen network adequacy standards for Medicare Advantage plans. A joint statement from the coalition urges Congress to pass a bill that would require insurers to publish a “patient‑friendly” network adequacy report and impose penalties for unjustified denials.

Conclusion

Ballad Health’s lawsuit against UnitedHealthcare represents a pivotal moment in the evolving battle over Medicare Advantage network adequacy and patient access. While UnitedHealthcare maintains that its practices are compliant with federal regulations, Ballad insists that the insurer’s contract changes constitute a deliberate strategy to reduce access and squeeze out providers. The outcome of the litigation will not only determine the fate of patients in southwestern Ohio but may also influence national policy on how insurance contracts are structured and monitored in the Medicare Advantage marketplace.