UnitedHealth Group, the largest U.S. health insurance provider, is facing a potential class action lawsuit alleging its use of an artificial intelligence (AI) algorithm systematically denied elderly patients’ claims for extended care.
The focal point of the lawsuit is an AI algorithm called nH Predict, developed by NaviHealth, a company acquired by UnitedHealth in 2020. The algorithm is purportedly used by the insurer to assess claims for post-acute care, including stays in skilled nursing facilities and in-home care.
According to the complaint, UnitedHealth used the algorithm to prematurely and in bad faith discontinue payment for healthcare services. When these denials are appealed to federal administrative law judges, approximately 90% are reversed, highlighting the alleged blatant inaccuracy of the algorithm. According to court documents, the AI is still in use.
The filing in Minnesota federal court was made on behalf of the family members of two deceased UnitedHealth beneficiaries, with both families claiming they were forced to pay out of pocket for medically necessary care due to claim denials by the insurer. The lawsuit contends that use of nH Predict violates contracts with patients and insurance laws in various states, and thus the plaintiffs are seeking a court order to stop the practice and award damages.
The plaintiffs' lawyers aim to represent a nationwide class of individuals on Medicare Advantage insurance plans, which are typically funded by Centers for Medicare & Medicaid Services (CMS) programs but administered by private health insurers like UnitedHealth.
In response to a request for comment, UnitedHealthcare told HealthExec:
“The NaviHealth Predict tool is not used to make coverage determinations. The tool is used as a guide to help us inform providers, families and other caregivers about what sort of assistance and care the patient may need both in the facility and after returning home. Coverage decisions are based on CMS coverage criteria and the terms of the member’s plan. This lawsuit has no merit, and we will defend ourselves vigorously.”
It isn’t yet clear if the lawsuit will be settled out of court and no trial date is currently set, as the suit is still seeking class action status.
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