In the back offices of health insurance firms, critical determinations on medical coverage eligibility have long been made. However, the landscape is evolving with the introduction of artificial intelligence algorithms that are now playing a role in these decisions, potentially impacting individuals’ lives.
Two families recently initiated legal action against UnitedHealth Group, alleging that the insurance giant utilized advanced technology to obstruct or reduce access to rehabilitation services for two elderly men in the period preceding their demise.
As per a federal lawsuit filed in Minnesota on behalf of the estates of two elderly Wisconsin residents, United Health’s artificial intelligence, or AI, is accused of making inflexible and unreasonable judgments regarding the necessary care for patients recovering from severe conditions. This has led to the denial of coverage for skilled nursing and rehabilitation facilities that should have been included under Medicare Advantage programs. The lawsuit contends that it is illegal to allow AI to supersede medical professionals’ recommendations for such individuals, advocating instead for assessments by qualified healthcare experts.
Despite evidence suggesting significant flaws in the AI’s assessment of patient needs, the families allege that the insurance company is deliberately withholding care from vulnerable elderly patients who are less likely to challenge these decisions. The lawsuit further claims that UnitedHealth utilized algorithms to dictate insurance coverage plans and override medical advice, despite the AI’s notably high error rate.
Court records reveal that more than 90% of state-level rejections were overturned through internal appeals or national administrative law judges. However, only a minute fraction of individuals contested the decisions made by these systems, with a mere 0.2% opting to challenge claim denials through the appeals process. Consequently, the lawsuit asserts that a substantial portion of individuals enrolled in United Health’s Medicare Advantage plans may end up bearing out-of-pocket expenses or foregoing a significant portion of their prescribed post-acute care.
Legal representatives for the plaintiffs argue that the exorbitant cost of these coverage denials is part of the insurance company’s profit-driven strategy, prioritizing financial gains over the well-being of the individuals they are obligated to serve. This conflict underscores a broader trend in the legal landscape where AI-driven decisions are increasingly scrutinized for their implications on patient care and insurance coverage.
The lawsuit specifically highlights the case of Gene B. Lokken and Dale Henry Tetzloff, both residents of Wisconsin covered by United Health’s private Medicare plans. Lokken, aged 91, suffered a leg and ankle injury in May 2022, necessitating immediate clinic care followed by a month of rehabilitation. Despite his physician’s recommendation for ongoing physical therapy to aid in his recovery, Lokken’s family faced repeated denials for continued coverage, ultimately bearing the financial burden of his care until his passing in July 2023.
Similarly, Tetzloff, aged 74, faced coverage challenges following a stroke recovery in October 2022, with the insurance provider attempting to cease coverage prematurely despite medical recommendations for extended rehabilitation. The family’s persistence in challenging these decisions resulted in additional coverage for Tetzloff, albeit with substantial out-of-pocket expenses incurred over the following months until his passing in October 2023.
These cases underscore broader concerns raised by Medicare advocates regarding the utilization of AI technologies in determining coverage eligibility for senior Medicare beneficiaries. The potential for AI algorithms to streamline or restrict coverage decisions, as highlighted in the lawsuit, raises questions about the role of human oversight in ensuring fair and equitable healthcare determinations.
Legal experts emphasize the importance of maintaining human involvement in the decision-making process, particularly in healthcare scenarios where AI systems may lack the nuanced judgment and empathy of human caregivers. While AI can offer speed and efficiency in processing data, the need for human intervention to validate and interpret these decisions remains paramount to safeguarding patient welfare and ensuring ethical healthcare practices.
In conclusion, the evolving landscape of AI-driven healthcare decisions necessitates a delicate balance between technological advancement and human oversight to uphold ethical standards and prioritize patient care above financial considerations.
