Optum and its parent UnitedHealth Group are defending an unusually broad slate of lawsuits and government actions, and the current Optum lawsuits touch nearly every part of the business: an AI tool blamed for wrongful Medicare Advantage denials, an FTC case over insulin pricing, opioid claims from states and counties, a Department of Justice probe into Medicare billing, an antitrust fight over the Amedisys acquisition, long-running mental health parity litigation, state Medicaid fraud suits, and class actions over billing codes and robocalls. Several have already produced settlements, injunctions, or court-ordered divestitures in 2025 and 2026; others are just entering discovery. Here is where each stands.
AI Denials of Medicare Advantage Care
The highest-profile case pending against UnitedHealth is Estate of Lokken v. UnitedHealth Group, filed in November 2023 in the District of Minnesota by the families of two deceased Medicare Advantage members. The suit targets an algorithm called nH Predict, used by UnitedHealth’s naviHealth subsidiary (now Home & Community Care), which the plaintiffs allege overrode treating physicians and cut off skilled nursing coverage prematurely.1Georgetown Law Litigation Tracker. Estate of Gene B. Lokken et al. v. UnitedHealth Group, Inc. et al.
The core allegation: nH Predict has a 90% error rate, meaning nine of ten denials are reversed on appeal, but only about 0.2% of policyholders appeal. The plaintiffs say that gap gave UnitedHealth a financial reason to deny first and rely on patient inaction.2CBS News. UnitedHealth Lawsuit Over AI Deny Claims in Medicare Advantage
Judge John R. Tunheim dismissed five of seven claims in February 2025 but let the case move forward on breach of contract and breach of the implied covenant of good faith and fair dealing, and waived the usual requirement that plaintiffs exhaust Medicare’s administrative appeals first.3Healthcare Finance News. Class Action Lawsuit Against UnitedHealth’s AI Claim Denials Advances In March 2026, a federal magistrate ordered UnitedHealth to hand over a broad set of internal documents going back to January 2017, including nH Predict design records, naviHealth acquisition materials, medical director performance reviews, and records from the company’s internal AI review board.4Becker’s Payer. Judge Orders UnitedHealth to Hand Over Broad Discovery in AI Coverage Denial Case The court pointed to a 2024 Senate investigation finding UnitedHealth’s denial rate for post-acute care claims more than doubled after nH Predict was rolled out.5Distilinfo. Court Orders UnitedHealth to Disclose AI Denial Algorithm
UnitedHealth’s position is that nH Predict is a guidance tool, not a decision-maker, and that coverage decisions rest on CMS criteria and plan terms.2CBS News. UnitedHealth Lawsuit Over AI Deny Claims in Medicare Advantage Similar suits are pending against Humana, which also uses nH Predict through naviHealth, and against Cigna over a different algorithm.6The Guardian. Health Insurers AI
FTC Insulin Pricing Case Against OptumRx
In September 2024, the Federal Trade Commission sued the three largest pharmacy benefit managers — OptumRx, CVS Caremark, and Express Scripts — alleging their rebating practices artificially inflated insulin list prices by steering patients toward higher-cost products that carried larger manufacturer rebates.7Federal Trade Commission. Pharmacy Benefits Managers (PBM)
Express Scripts settled in early February 2026, agreeing to delink compensation from negotiated savings and stop favoring high-list-price drugs. CVS Caremark reached a proposed settlement in late March 2026. OptumRx was the last to move: in June 2026, the company and the FTC jointly paused the case to finalize a tentative deal. The FTC’s competition and consumer protection directors have approved a proposed consent agreement, though its terms have not been made public. OptumRx continues to deny the allegations.8Healthcare Dive. UnitedHealth Optum Rx FTC Proposed Settlement Insulin Case9BenefitsPRO. Optum Rx Becomes Final PBM to Reach Settlement With FTC Over Insulin Pricing
Opioid Litigation
OptumRx is one of roughly 80 PBM defendants in the federal opioid multidistrict litigation consolidated in Cleveland under In Re: National Prescription Opiate Litigation (No. 1:17-md-02804). As of early 2026 the PBM tranche is still in pretrial stages before Judge Dan Aaron Polster, with no trial date set.10Reuters. Optum, Express Scripts Seek to Oust Judge in Opioid Cases
On December 8, 2025, West Virginia Attorney General John McCuskey filed a federal lawsuit accusing OptumRx of conspiring with drug companies to increase painkiller supply, pushing to raise daily dosage limits, penalizing clients that tried to impose dispensing restrictions, and dispensing opioids through mail-order pharmacies without adequate controls. The state brings claims under the West Virginia Consumer Credit and Protection Act, the federal RICO statute, and negligence.11Reuters. West Virginia Sues UnitedHealth Group’s Pharmacy Benefit Manager Over Opioid OptumRx said the suit “misrepresents Optum’s longstanding commitment to addressing a public health crisis that it neither caused nor encouraged.”12Becker’s Payer. West Virginia Sues UnitedHealth’s Optum Over Opioid Crisis
In an unusual move, OptumRx has also gone on offense against local plaintiffs. In June 2025, it sued five Kentucky counties — Anderson, Boyd, Christian, Nicholas, and Oldham — claiming they violated the state’s open meetings law when they voted behind closed doors to join the national opioid litigation. All five counties moved to dismiss, with hearings scheduled for late August and early September 2025.13Kentucky Lantern. Goliath vs. David: Optum Rx Invokes Open Meetings Law to Fight Kentucky Counties on Opioid Suits
There is one resolved federal opioid matter. In June 2024, OptumRx paid $20 million to resolve allegations that a now-closed mail-order pharmacy in Carlsbad, California, filled “trinity” prescriptions — opioids combined with benzodiazepines and muscle relaxants — between April 2013 and April 2015 without resolving red flags that the prescriptions lacked a legitimate medical purpose. The settlement carried no determination of liability and resolved claims brought by the DEA and the U.S. Attorney’s Office for the Southern District of California.14U.S. Department of Justice. OptumRx Agrees to Pay $20M to Resolve Allegations It Filled Certain Opioid Prescriptions in Violation
DOJ Medicare Investigations
UnitedHealth Group disclosed in July 2025 that it is cooperating with both criminal and civil Department of Justice investigations into its Medicare business, and said it “proactively reached out” to the DOJ after news reports of the probe.15The New York Times. UnitedHealth Medicare Justice Department Reporting has indicated the criminal division is looking at OptumRx’s prescription management services and at how UnitedHealth reimburses its own doctors, including how patient diagnoses are documented to trigger additional Medicare payments.16Modern Healthcare. DOJ UnitedHealth Optum Rx Medicare Billing
Amedisys Merger Settlement
The DOJ and the attorneys general of Maryland, Illinois, New Jersey, and New York sued in November 2024 to block UnitedHealth’s $3.3 billion acquisition of home health and hospice provider Amedisys on antitrust grounds.17U.S. Department of Justice. US and Plaintiff States v. UnitedHealth Group Inc. and Amedisys, Inc. The case resolved through a court-approved settlement in December 2025 that requires UnitedHealth and Amedisys to divest at least 164 home health and hospice locations across 19 states, worth roughly $528 million in annual revenue. Amedisys was also ordered to pay a $1.1 million civil penalty for false certifications under the Hart-Scott-Rodino Act. A modified final judgment was issued in February 2026.18U.S. Department of Justice. Court Approves Justice Department’s Settlement With UnitedHealth Group and Amedisys Merger
Mental Health Parity and Wit v. United Behavioral Health
Optum’s behavioral health subsidiary, United Behavioral Health (UBH), has been in litigation for years over claims it imposed stricter coverage limits on mental health and substance use treatment than on comparable medical care, in violation of the federal Mental Health Parity and Addiction Equity Act.
Wit v. United Behavioral Health, a class action for roughly 65,000 employee health plan participants, returned to the district court after multiple Ninth Circuit rounds. In August 2025, Magistrate Judge Joseph C. Spero ruled that the plaintiffs’ fiduciary breach claims remain viable, finding UBH prioritized financial interests over member interests between 2011 and 2017. Because the appeals court had ruled out reprocessing of individual claims as a remedy, plaintiffs are seeking injunctive and declaratory relief.19Behavioral Health Business. District Court Sides With Plaintiffs in Wit v. United Behavioral Health After Years of Appeals In February 2026, the court extended an injunction through February 2031 requiring UBH to use ERISA coverage criteria that accurately reflect generally accepted standards of care.20The Kennedy Forum. Wit
In March 2026, UnitedHealth separately settled a related class action for $1.4 million over denials of coverage for mental health and substance use treatment at residential facilities, with individual payouts ranging from about $937 to $18,734.21Behavioral Health Business. UnitedHealth Group Settles Case for $1.4M Over SUD Mental Health Treatment Claim Denials Earlier behavioral health resolutions include a 2021 settlement following a Department of Labor investigation, a separate 2021 class action settlement, and a 2021 New York and DOJ settlement after regulators found the company had denied more than 34,000 therapy sessions in New York between 2013 and 2020 using an algorithmic system called ALERT. UnitedHealth agreed to stop using ALERT; ProPublica later reported the company launched a similar program called Outpatient Care Engagement.22ProPublica. UnitedHealth Mental Health Care Denied Illegal Algorithm
State Attorney General Actions
Massachusetts Medicaid Fraud Suit
On May 29, 2026, Massachusetts Attorney General Andrea Joy Campbell sued UnitedHealthcare in Suffolk Superior Court, alleging the insurer defrauded MassHealth of at least $100 million. The complaint accuses UnitedHealthcare of manipulating health assessments for seniors in its Senior Care Options plan, classifying members at higher-severity payment tiers without corresponding diagnoses, and billing for daily skilled nursing services members did not receive. Campbell alleges the company employed a “growth at all costs” strategy that pushed field nurses to inflate member severity.23Massachusetts Attorney General. AG Campbell Sues United Healthcare for Defrauding MassHealth Out of $100 Million UnitedHealthcare called the suit “meritless” and said the AG’s account does not accurately describe the Senior Care Options program.24Mass Lawyers Weekly. UnitedHealthcare Defrauded MassHealth of $100M, AG Alleges
Louisiana Medicaid Drug Pricing Suit
Louisiana Attorney General Jeff Landry sued UnitedHealth and OptumRx in state court in April 2022, alleging they inflated prescription drug costs in the state’s Medicaid program by “billions” and that Optum raised drug costs to help UnitedHealthcare meet required medical loss ratio targets for its Medicaid managed care plans.25Fierce Healthcare. Louisiana AG Sues UnitedHealth Alleging Drug Overcharges Medicaid The case is active. In November 2025, the Louisiana Court of Appeal reversed a lower court ruling that had dismissed OptumRx’s challenge to the state’s contingency-fee contract with its outside counsel, sending the issue back for further proceedings.26FindLaw. Louisiana Court of Appeal, First Circuit
Oklahoma Cease-and-Desist
Oklahoma Attorney General Gentner Drummond issued a cease-and-desist letter to OptumRx in November 2025 over the company’s practice of retroactively clawing back pharmacy reimbursements after discovering it had applied an incorrect pricing list for several months. Drummond called the practice “unlawful,” “deceptive,” and “discriminatory,” and warned that continued violations could bring penalties of up to $10,000 per violation and potential license suspension in Oklahoma.27The Journal Record. Oklahoma Attorney General OptumRx Cease Desist
Dummy Codes Settlement in Peters v. Aetna
A federal court in North Carolina approved an $8.4 million settlement in September 2025 in Peters v. Aetna Inc., a 2015 class action alleging Aetna and Optum Health used fabricated billing codes labeled “Administrative Add-On Services” to disguise Optum’s administrative fees as medical expenses, inflating patients’ out-of-pocket costs for chiropractic and physical therapy. The complaint alleged the practice breached fiduciary duties under ERISA. Aetna paid $4.6 million and Optum paid $200,000, with about $3.6 million going to attorneys’ fees.28Healthcare Finance News. Aetna, Optum Pay $8.4 Million to Settle Dummy Codes Lawsuit29Bloomberg Tax. Aetna, Optum Cleared for $8.35 Million Dummy Code Settlement
Robocall Settlements Under the TCPA
Two class action settlements have resolved claims that UnitedHealth and OptumRx violated the Telephone Consumer Protection Act by placing automated calls to cell phones without authorization.
In Patterson v. OptumRx, Inc., filed in the Southern District of Indiana, OptumRx agreed to pay $1.86 million over prerecorded “clinical adherence” calls placed to non-customers between April 2020 and October 2025. Payments to approved claimants went out in May 2026, with individual awards estimated between $72 and $135.30ClassAction.org. $1.86M OptumRx Settlement Ends Litigation Over Alleged Prerecorded Voice Messages
In Johnson v. United HealthCare Services, Inc., filed in Florida, UnitedHealthcare agreed to a $3.495 million settlement over automated calls about the Optum HouseCalls program directed to people who were not the intended plan members. The court granted preliminary approval in February 2025, with individual awards estimated between $50 and $125.31ClassAction.org. $3.495M United Healthcare Settlement Resolves Optum HouseCalls Class Action Lawsuit
Emanate Health Antitrust Suit
Emanate Health, a nonprofit hospital system in California, sued Optum Health for antitrust violations in November 2023 in the Central District of California. The complaint alleges Optum tried to monopolize the primary care market through coercive physician non-compete agreements, lied to patients about the status of departing doctors by telling them the physicians had retired or were on vacation, and retaliated against Emanate by not renewing hospital service contracts after Emanate refused to exit the primary care business. Emanate says the retaliation caused a significant drop in hospital admissions.32Becker’s Hospital Review. Optum Faces Antitrust Lawsuit From California Health System In July 2024, a federal judge ordered certain Emanate entities that had signed arbitration clauses with Optum to arbitrate their claims; the case is still pending.33Source on Healthcare. Emanate Health et al. v. Optum Health et al.