Texas Attorney General Ken Paxton has launched investigations into UnitedHealth Group and Blue Cross Blue Shield of Texas over allegations that the companies delayed or denied urgent, medically necessary care to patients, including newborns and adults with serious illnesses. The probes focus on whether insurers' coverage decisions have overridden physicians' medical judgment, potentially putting patients at risk and violating state law.

Explainer Attorney General Ken Paxton’s Legal Impact on Texas Policies and Public Safety

The investigations highlight a growing conflict over who is responsible when insurance companies control access to medical care, and whether current oversight is sufficient to protect patients.

The issue has drawn attention from lawmakers and patients after reports surfaced of insurers allegedly denying or retroactively withdrawing approval for procedures deemed necessary by treating physicians. In one case cited by Paxton's office, a Texas patient received approval from UnitedHealth for a procedure, only to have the approval rescinded after the operation, leaving the patient with a significant bill. Paxton said his office "will gather the evidence, stand up to this multinational conglomerate, and make sure Texans get the coverage they pay for."

Allegations Against Insurers

According to the Texas Attorney General's office, UnitedHealth is under scrutiny for allegedly engaging in deceptive and unlawful practices, including bribing nursing homes to delay hospitalizations and overriding doctors' recommendations. Blue Cross Blue Shield faces similar allegations of delaying or denying urgent care, such as a newborn's transfer for treatment. Both investigations invoke the Texas Deceptive Trade Practices Act, which prohibits deceptive conduct and undisclosed financial incentives in business dealings.

"No Texan should be denied medically necessary care, dragged through endless appeals, or stuck with devastating bills after trusting their insurer’s word."

— Ken Paxton, Texas Attorney General

Patients and clinicians have described how insurance requirements—such as prior authorization, step therapy, and peer-to-peer medical reviews—can delay or block access to prescribed treatments. At a recent Texas House hearing on women's health, nurse practitioner Shelagh Larson testified that a breast cancer survivor was required by her insurer to try antidepressants and anti-seizure drugs before receiving an FDA-approved nonhormonal treatment for severe hot flashes. Larson said the insurer's initial reviewer was a podiatrist, not a women's health specialist, and only after consulting a gynecologist was the treatment approved.

Texas law requires that peer-to-peer medical reviews be conducted by a physician licensed in the same or similar specialty as the treating doctor for certain cases. However, lawmakers questioned whether insurers consistently follow this rule. An industry representative told legislators, "I really hope we’re following," when asked about compliance.

The Texas Department of Insurance (TDI) regulates only about 22% of health plans in the state and does not routinely review the clinical basis of insurers' denial decisions, according to testimony at the hearing. TDI also lacks comprehensive data on claims and denials, making oversight challenging.

Recent legislation prohibits insurers from using automated decision systems, including artificial intelligence, to make adverse determinations about medical necessity or appropriateness. Under Texas Insurance Code Section 4201.156, such decisions must be made by qualified clinicians, not algorithms. The law also requires denial notices to specify the clinical basis for the decision and the procedures for appeal.

Appeals and Accountability

Data from insurer Ambetter from Superior HealthPlan showed that in 2025, 62% of appealed denials were reversed, but only about 5% of all standard denials were appealed. Lawmakers and patient advocates argue that the low appeal rate may reflect barriers to challenging denials rather than a lack of problems.

Some medical professionals, such as Dr. Heidi Russell, a pediatric oncologist, have criticized insurers for requiring patients to fail on insurer-preferred drugs before accessing prescribed treatments, warning that delays can have serious health consequences. Russell stated that "these corporations are practicing medicine without a license."

Insurers and their representatives maintain that coverage decisions are based on medical necessity and scientific evidence, and that physician reviewers are responsible for evaluating whether treatments meet those standards. Industry officials have not directly addressed the specific allegations raised in the investigations.

Legislative and Regulatory Responses

Texas lawmakers are considering reforms to increase transparency and accountability for insurers' medical decisions. Proposals include requiring disclosure of who made coverage determinations, what evidence was used, and whether financial incentives played a role. Some advocates point to a new Tennessee law that recognizes clinical-appropriateness determinations as the practice of medicine, subjecting them to professional standards and oversight.

The investigations by Attorney General Paxton remain ongoing. Civil Investigative Demands have been issued to UnitedHealth Group to collect evidence of potential violations. No timeline for the completion of the probes has been announced.