TL;DR:
- Class-action lawsuit alleges UnitedHealth Group used a faulty AI algorithm to deny Medicare coverage for rehabilitation care.
- The lawsuit follows STAT’s investigation into the company’s AI technology usage.
- Lead plaintiffs represent patients denied coverage for post-acute care.
- UnitedHealth Group denies the allegations, claiming the lawsuit lacks merit.
- Growing skepticism regarding health insurers denying payment for necessary medical services.
- The lawsuit alleges AI overrides physicians’ recommendations with a 90% error rate.
- UnitedHealth Group emphasizes AI is a guide, with coverage decisions based on federal criteria and plan terms.
- Allegations of employees being limited in deviating from AI projections.
- The lawsuit highlights potential financial gain for the company at the expense of patient care.
- UnitedHealth Group’s continued use of the flawed AI model due to limited patient appeals.
- AI model “nH Predict” is used to forecast patient recovery in post-acute settings.
- Plaintiffs claim the company capitalizes on patients’ vulnerability to uphold AI-driven decisions.
- Previous legal actions against UnitedHealth Group for denying provider claims.
Main AI News:
A recent class-action lawsuit has brought to light allegations that UnitedHealth Group, headquartered in Minnetonka, has been utilizing a flawed artificial intelligence (AI) algorithm to reject claims for rehabilitation care under Medicare erroneously. The lawsuit, filed in the U.S. District Court of Minnesota, follows an investigation by STAT, a prominent news website, into the company’s AI technology usage.
The plaintiffs, primarily representing the families of two patients from north-central Wisconsin, contend that they were burdened with substantial out-of-pocket expenses due to coverage denials for post-acute care. UnitedHealth Group has vehemently denied the accusations, asserting that the lawsuit lacks merit.
This legal battle emerges against a backdrop of heightened skepticism from both consumers and government entities regarding health insurers’ propensity to deny payment for crucial medical services. The lawsuit alleges that UnitedHealth Group’s deployment of AI in lieu of medical professionals has led to wrongful denial of care to elderly patients covered by Medicare Advantage plans, often overriding the recommendations of their treating physicians. The AI model in question purportedly carries a staggering 90% error rate.
UnitedHealth Group, the largest Medicare Advantage coverage provider in the nation, maintains that the technology in question serves as a guide rather than a sole determinant for coverage decisions. They emphasize that coverage determinations are ultimately based on federal criteria and the member’s plan terms.
However, the lawsuit argues that the company restricts its employees’ ability to deviate from AI projections, citing disciplinary actions and terminations for non-compliance. This, the complaint alleges, enables UnitedHealth Group to profit by collecting policy premiums without fulfilling the promised care, leaving elderly patients prematurely discharged or depleting family savings to secure essential medical attention.
The lawsuit contends that the flawed AI model remains in use, primarily because very few patients traditionally challenge health insurance denials. Even when patients attempt to appeal, as some plaintiffs did, they often end up bearing the financial burden themselves or forgoing necessary post-acute care.
UnitedHealth Group relies on a model called “nH Predict” to forecast the expected duration of patient recovery in facilities such as nursing homes and post-acute settings. This AI-powered tool evaluates mobility, activity level, and cognition scores to estimate the length of stay in a skilled nursing facility.
The plaintiffs assert that UnitedHealth Group capitalizes on patients’ compromised conditions, limited awareness, and lack of resources to contest AI-driven decisions. This legal action follows a previous lawsuit by the U.S. Department of Labor against a UnitedHealth Group subsidiary, accusing the company of wrongly denying thousands of healthcare provider claims for emergency room services and drug screenings.
This case underscores the growing scrutiny within the healthcare industry, with Nebraska regulators recently imposing a $1 million penalty on Bright Health for alleged errors in claims processing, including numerous newborn medical care denials. Last year, the Office of the Inspector General at the U.S. Department of Health and Human Services revealed that about 13% of prior authorization denials by Medicare Advantage plans met coverage rules, potentially necessitating reimbursement under original Medicare.
Conclusion:
The lawsuit against UnitedHealth Group highlights the increasing scrutiny of the healthcare insurance industry’s use of AI in making coverage decisions. It underscores the need for transparency and accountability in AI-driven processes, which could impact market dynamics and push insurers to reassess their AI utilization to maintain consumer trust and avoid legal challenges.
