As we approach 2026, the future of healthcare and our patients is still fraught with uncertainty, frustration, and chaos. There is a battle for control of the delivery, services, and resources for healthcare that is stronger than we have seen before. Private equity is investing billions of dollars in healthcare—from all directions—but not in traditional channels. Those investors and groups come from outside the physician medical practice and the hospital system and have the potential to drastically reshape healthcare delivery. Algorithms and emerging artificial intelligence (AI) are changing the conversations around utilization management between payers, patients and providers. The question of physician autonomy and who is actually determining medical necessity for unique patient needs is seriously in jeopardy.
Control Through Consolidation
Independent oncology practices have been able to maintain their practice identities, but as a method of survival, consolidated or aligned with physician networks, including OneOncology, US Oncology, ONCare Alliance, and others. Many formerly private practices have been acquired in record numbers, not just by healthcare systems and hospitals, but also now by private equity and corporate entities and consolidated into these organizations.
UnitedHealthcare is the country’s largest health insurance company, controlling 15% of the US market. Optum Rx is the third-largest pharmacy benefit manager in the country by market share, with approximately 23% of the 2024 processed drug claims. Optum Health (Optum), a subsidiary of UnitedHealthcare, is considered the largest employer of physicians in the country. Optum now employs or is affiliated with more than 90,000 doctors, controlling about 10% of the US physician workforce.
Optum has been under investigation for much of 2025 for its growing market control over insurance, pharmacy, doctors, and even software used internally and by other payers across the country to process claims and payments.1 In the face of multiple criminal investigations related to billing and coding practices, physician compensation, as well as the general national pressure on pharmacy benefit managers (PBMs), insurance rates, and corporate involvement in medical decision-making—it will be very interesting to watch how the growing Optum control of its physicians within the parent company plays out in 2026.
Horizontal and Vertical Integration Leads to Control Outside of the Parent Company
Horizontal and vertical integration of private entities seeking control in the healthcare market has led to often unrecognized control that spreads across payers for patient utilization, coverage policy, and access to care issues. Patients and physicians may find themselves burdened by surprisingly similar access issues from not 1, or 2, but several of the key payers in their market area.
naviHealth is an algorithm/AI software sold by Optum to other payers for control of coverage for discharged patients admitted to secondary rehabilitation facilities.2 This Optum-owned utilization management software was the primary subject of an October 17, 2024, Senate report as a tool by which Medicare Advantage insurers would deny patients access to post-acute care. The report focused on UnitedHealthcare, Humana, and Aetna (CVS) (the 3 largest Medicare Advantage insurers) and their use of the same naviHealth software as provided by Optum.
Optum for Business,3 another subsidiary of UnitedHealthcare, provides software programs and support for other large and small payers outside of UnitedHealthcare. Their solutions control the gamut of the claim lifecycle, including these programs:
- Coding Advisor (Service)—reduce common billing errors with our proven provider education. 81% of providers demonstrate positive behavioral change
- Claim Pricing Solutions (Software)—improve the accuracy and efficiency of your prospective payment system pricing
- Claims Edit System (Software)—achieve clean claims and maximize medical spend savings with our flexible, real-time claim editing software
- Claim Review (Service)—prevent improper payments, reduce medical spend, and minimize provider abrasion with our comprehensive suite of pre- and post-pay solutions
- Coordination of Benefits (Service)—identify and validate primary policy coverage with accurate eligibility data
- Credit Balance Resolution Services (Service)—identify, research, and resolve overpaid claims
Control of Medical Necessity—MD or Other?
A physician has direct knowledge of and eyes on their patient. The physician determines healthcare services or procedures as reasonable, necessary, and appropriate based on clinical standards and patient-specific conditions. Unfortunately, as control of physician services and horizontal and vertical integration of payer and other entities has grown in healthcare, the actual determination of what is medically necessary and appropriate for the patient may well be determined by control or decision-making beyond the scope of the physician.
Physicians will often use specialty-driven, evidence-based guidelines to both guide and support their clinical decisions for each patient. However, those recommendations are now often subverted or superseded by corporate entities such as PBMs, payers, utilization review companies, or other third parties that intervene between the physician’s treatment decisions and the patient’s ability to actually receive, access, or even receive financial coverage for other choices than the physician-recommended decisions.
Payers and those other intervening entities may start with some source for evidence-based guidelines, but then layer on other parameters that could include Medicare National and Local Coverage Determinations, commercial plan rules, or other utilization management criteria. More and more frequently, physicians are being informed (by these external entities with no direct knowledge of the patient) that their medically necessary decision for a patient will not be covered or allowed and given alternative choices if they wish to continue to treat the patient.4
Concerns for the Future of Healthcare
If your practice is already having issues with UnitedHealthcare disruption of patient access to care and coverage, what does this mean when UnitedHealthcare owns more doctors in the country than anyone else and can control the care choices they provide? How much more difficult does advocating for patients become when even different payers are using common software to execute utilization and claim management? What happens when you think you are calling an independent payer, whether an Anthem plan or a regional plan, but do not realize that the software and possibly even the staff you are speaking with are owned/developed/controlled by UnitedHealthcare? Have we reached a tipping point where big insurance companies will be restricted in gaining control over medical practices and medical utilization, or will the independent physician or healthcare system be absorbed by continued expansion of large for-profit entities?
What Can Practices Do?
Practices, whether private or part of a hospital system, should have access to networks to address common advocacy issues and utilization management challenges. Those networks could include the state oncology society, or larger networks of independent practices or within a clinically integrated health system. Sharing challenges may lead to revelations that similar challenges or care control issues may suddenly present consistently across various payers. That could be an indicator of a common software being in use from a single source like Optum.
Understanding the commonality of the challenge may create opportunities for multiple physicians to raise their concerns in a common voice. When multiple patients are adversely affected by one consistent process or software that may be the result of integration or controlling tools that cross different insurers, we must recognize those patterns in order to be able to address them with regulators or legislators. Many states have insurance and healthcare commissions in their state legislature and governance structure. We need the voice of the medical community in the offices of those commissions, in front of the legislators, state departments, and their staff. We need to bring the voice of reason and practicality to these conversations. I myself testified on most of these topics this legislative season in Connecticut and would be happy to share talking points with anyone considering raising these issues in their own state.
Next Steps for Cancer Practices:
- Look for patterns of commonality in claims and utilization management policies, even across diverse insurers
- Collaborate, inform, and join forces with others facing similar challenges, local, state, and federal leadership
- Comment on and address federal and state legislation and policy that may have a positive or adverse effect on the impact of patient care, coverage, and policies
Share your thoughts and experiences with me at
References
- Emerson J. UnitedHealth criminal probe goes beyond Medicare: Report. Beckers’ Payer Issues. August 26, 2025. www.beckerspayer.com/payer/unitedhealth-criminal-probe-goes-beyond-medicare-report/
- Holcombe D. Artificial intelligence, algorithms, and abuse. Oncology Practice Management. February 2025. https://oncpracticemanagement.com/issues/2025/february-2025-vol-15-no-2/artificial-intelligence-algrithms-and-abuse
- Optum for Business. Payment integrity solutions for health plans. Accessed November 11, 2025. https://business.optum.com/en/operations-technology/payment-integrity.html
- Lineberry S. Medical necessity 101: what providers must know to optimize reimbursement. IMOHealth. July 24, 2025. www.imohealth.com/resources/medical-necessity-101-what-providers-must-know-to-optimize-reimbursement/