$14.6 billion in fraud. The 2025 DOJ Takedown, the largest ever. One billion catheters billed. A couple makes $615 million from fake wound care. While the government chases criminals, insurers legally deny billions in legitimate claims. Using AI. With 90% error rates. When a UnitedHealthcare CEO was killed, 57,000 reacted with laughing emojis. This episode explains why.

WHAT WE COVER:

Criminal Fraud: Operation Gold Rush: Russian organization steals $941M using 1M stolen identities | Arizona couple: $1.2B billed, $615M received, $68M seized | 324 defendants, 96 were medical professionals | Why both government and private insurers get defrauded

"Delay, Deny, Defend": From Jay Feinman's 2010 book | 20% claims denied (2023 average) | Only 1% appeal | 50% of appeals win | Half the denials were wrong | Industry playbook: delay, deny on technicalities, defend aggressively

The AI Scandal: UnitedHealth nH Predict lawsuit: alleged 90% error rate | When appeals happen, 90% reversed | Federal judge allows suit (Feb 2025) | Cigna's PXDX batch denials | UnitedHealth denials doubled: 10.9% (2020) to 22.7% (2022)

The Numbers: $260B hospital claims denied annually | 85% "non-emergent" ER denials were actual emergencies | 93% of doctors: prior auth delays care | 29% report serious adverse events/deaths | CEO pay: Witty $26.4M, Cordani $23.3M (200-370:1 ratios)

Real Stories: Heart procedure pre-approved then denied for "spinal injections" never received | Newborn denied NICU day 4 | Stroke patient: $70K out-of-pocket, dies during appeals | Mental health denied, told "if she dies, Medicaid pays" | Fighting insurance as "second job" while sick

Both Sides: Conservative: Prior auth prevents fraud/overutilization | Progressive: Profit motive incompatible with care | Reality: System both wasteful AND stingy | Insurance margins 3-5% but entire ecosystem profits

Solutions: 12+ states regulating AI in claims | Pennsylvania overturned 50% of denials | Bipartisan reform efforts | Free AI tool fights denials | HSA expansion vs Medicare for All debate

COMING PART 3: Mangione case, evidence, trial, folk hero status, what public reaction reveals

SOURCES: DOJ: 2025 ($14.6B) & 2024 ($2.75B) Fraud Takedowns | Operation Gold Rush | Gehrke/King Arizona case | Estate of Lokken v. UnitedHealth (Nov 2023) | Cigna PXDX lawsuit (July 2023) | Federal ruling (Feb 2025) | Senate Subcommittee report (Oct 2024) | Kaiser Family Foundation denial surveys | AMA prior auth surveys | PMC/NCBI insurance denial studies | STAT News | CBS News | PBS News | Healthcare Finance News | Becker's CEO compensation | Feinman "Delay, Deny, Defend" (2010)

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CONTENT WARNING: Healthcare failures, fraud, death, serious illness stories. Listener discretion advised.

DISCLAIMER: Educational/entertainment only. We present facts and multiple perspectives, not policy advocacy. Not medical/legal experts. Lawsuits reflect allegations, not proven facts. UnitedHealth denies AI claims; cases ongoing. CEO figures from public filings. Fraud cases from DOJ. Nothing condones violence. We examine systemic issues to understand frustration, not justify acts. Part 2 of 3.

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