According to a class action lawsuit filed on Tuesday, UnitedHealth Group, headquartered in Minnetonka, inaccurately denies Medicare patients requiring treatment post-hospitalization coverage by utilizing an erroneous artificial intelligence algorithm.
Following an investigative report by web STAT regarding the company’s utilization of these systems, the complaint was submitted to the U.S. District Court of Minnesota.
The plaintiffs directly involved are households of two individuals residing in north-central Wisconsin, approximately three hours south of the Twin Cities, necessitating long-term care in post-acute facilities.
As per the legal claim, United Health’s Medicare Advantage health plans declined payment for claims submitted by the patients’ medical providers, resulting in up to $70,000 in out-of-pocket expenses for ongoing care.
The lawsuit alleges that UnitedHealth’s deployment of artificial intelligence in lieu of medical professionals led to the wrongful denial of elderly patients’ entitled care under Medicare Advantage plans. This denial was based on an AI model with a reported 90% error rate, overriding the treating physicians’ assessments of medical necessity.
United Healthcare, a major health insurer based in Minnetonka, dismissed the validity of the allegations.
The company clarified that the AI application serves as a tool to aid in educating caregivers, including providers and families, about the necessary support and care for patients during and post-service. Treatment decisions are purportedly aligned with CMS coverage guidelines and individual plan terms.
UnitedHealth is a leading provider of Medicare Advantage insurance, offering seniors the option to receive government benefits through private insurers.
The lawsuit contends that UnitedHealth Group restricts employees from deviating from the AI projections, disciplining or terminating them if they fail to adhere to the model, irrespective of patients’ actual care needs.
The fraudulent scheme allegedly allows the company to profit from policy premiums without providing guaranteed care, leading to elderly individuals being discharged from care facilities nationwide or exhausting family savings to access essential medical services.
Due to the low rate of patients challenging insurance denials, UnitedHealth purportedly continues to rely on the flawed AI model. The defendants in the lawsuit attempted to contest the company’s decisions but ultimately resorted to substantial out-of-pocket payments for necessary care.
UnitedHealth Group’s predictive tool, “nH Predict,” estimates recovery durations in care facilities and post-acute settings by assessing cognition, activity levels, and mobility, as indicated in a May 2020 report by NaviHealth, a Tennessee-based company. This information is shared with the patient’s health plan to inform care authorization decisions.
