The lawsuits have been brought against UnitedHealth by the families of two deceased former UnitedHealth beneficiaries, alleging that the health insurance company intentionally utilized flawed artificial intelligence algorithms to reject coverage for necessary expanded care recommended by their physicians.
Filed in federal court in Minnesota last Tuesday, the lawsuit contends that UnitedHealth unlawfully withheld essential care from elderly patients covered under Medicare Advantage Plans by relying on an AI model with a purported 90% error rate. This model allegedly overrode doctors’ recommendations regarding the medical necessity of certain expenses.
Medicare Advantage programs, approved by the U.S. Centers for Medicare and Medicaid Services, are administered by private insurers like UnitedHealth and offer seniors an alternative to traditional national health insurance.
The complaint asserts that UnitedHealth terminated payments to elderly beneficiaries prematurely and in bad faith, leading to their suffering from health and financial difficulties. This premature action was allegedly facilitated by the utilization of the flawed AI model known as “nH Predict,” developed by NaviHealth.
The families claim that UnitedHealth’s AI system contradicts doctors’ assessments, resulting in premature discharge of elderly patients from care facilities nationwide or forcing them to deplete family savings to continue receiving necessary medical treatment.
Aaron Albright, a spokesperson for NaviHealth, stated that the AI tool is intended to assist UnitedHealth in informing providers about patients’ care needs rather than making coverage decisions. He dismissed the lawsuit’s validity, emphasizing that policy determinations are guided by CMS regulations and member plan terms.
Despite potential benefits such as automating 50% to 75% of manual tasks related to insurance approval processes, as noted by McKinsey, medical professionals caution against overreliance on AI in the healthcare sector. The American Medical Association (AMA) supports the use of AI to expedite prior authorization but emphasizes the importance of human review in patient care decisions.
In light of these developments, it is crucial for health insurers to strike a balance between leveraging AI for efficiency gains and ensuring that human oversight remains integral to safeguarding patient well-being.
