The primary health insurance provider in the United States, United Healthcare, is accused of disregarding medical professionals’ decisions and unjustly withholding essential health coverage from elderly patients through a flawed AI algorithm. This has led to patients depleting their savings to cover treatments that should be included in their government-funded Medicare Advantage Plan, as they are prematurely discharged from treatment programs and care facilities.
A recent petition filed in the US District Court for the District of Minnesota highlights the grievances of two deceased individuals who were denied health insurance by UnitedHealth. The lawsuit seeks class-action status for individuals facing similar situations nationwide, potentially numbering in the thousands.
Coinciding with this legal action is an investigation by Stat News that corroborates the claims made in the lawsuit. Internal documents, communications, and interviews with former NaviHealth employees, the UnitedHealth division responsible for the AI algorithm nH Predict, form the basis of the investigation’s findings.
The nH Predict algorithm, implemented by UnitedHealth since at least November 2019, predicts the post-acute care needs of Medicare Advantage Plan patients following serious health events. Despite drawing from a database of 6 million clinical cases, the algorithm overlooks critical factors affecting a patient’s health and recovery, such as comorbidities and unforeseen complications during treatment.
The lawsuit and Stat’s research reveal discrepancies between nH Predict’s recommendations and standard Medicare guidelines, leading to premature discharge of patients from care facilities. UnitedHealth’s refusal to disclose nH Predict’s reports to patients or their physicians further exacerbates the situation, with medical professionals’ recommendations often disregarded.
The healthcare industry has a history of flawed AI utilization, with UnitedHealth’s approach focusing on cost-cutting and expedited care rather than individual well-being. Former employees attest to the company’s shift towards strict adherence to the algorithm’s predictions, penalizing deviations from projected lengths of stay in care facilities.
UnitedHealth’s response emphasizes that nH Predict serves as a guide to inform caregivers about patients’ potential care needs, considering individual programs and CMS coverage requirements. While case managers do not make coverage decisions, they play a crucial role in advocating for patients within the system.
Despite successful appeals against AI-driven coverage denials, patients find these victories short-lived as UnitedHealth reissues denials shortly after. The company’s profit-driven approach is evident in its relentless denial of coverage, even after appeals, leaving families burdened with substantial out-of-pocket expenses.
The lawsuit accuses UnitedHealth and NaviHealth of contractual breaches, unfair practices, and violations of insurance laws, seeking damages, emotional distress compensation, and an end to AI-driven coverage denials. The financial savings accrued by UnitedHealth through nH Predict are estimated to be substantial, reflecting the company’s prioritization of cost-efficiency over patient care.
