UnitedHealthcare Faces Lawsuit Alleging Faulty AI Algorithm Denies Healthcare Claims
Leading US health insurance firm UnitedHealthcare is facing a lawsuit filed in Minnesota that claims the company wrongfully denied healthcare claims using a faulty AI algorithm. The lawsuit, filed on behalf of two elderly men, alleges that UnitedHealthcare has repeatedly refused to pay the healthcare claims of senior patients enrolled in their Medicare Advantage Plans. It is claimed that UnitedHealthcare has been relying on advice from a flawed algorithm, resulting in the denial of medically necessary post-acute care.
Medicare Advantage is a government-approved version of the federal Medicare program, providing health coverage for American citizens or residents aged 65 and above. Approximately 31 million people in the US rely on Medicare Advantage. However, a recent report from the Inspector General of the US Department of Health and Human Services highlighted that private Medicare Advantage programs deny around 13 percent of service authorization requests that would have been approved by government-run Medicare.
The lawsuit alleges that UnitedHealthcare unlawfully deployed an AI system with a 90 percent error rate. This AI system, known as the nH Predict AI Model, has reportedly overridden recommendations from physicians regarding post-acute care for the elderly. Instead, it produces generic care recommendations that fail to consider individual patient needs and conflicts with Medicare Advantage coverage rules. The lawsuit claims that UnitedHealthcare has instructed its employees not to deviate from the algorithm’s predictions and takes disciplinary action against those who do.
Under Medicare Advantage Plans, patients who have a three-day hospital stay are typically entitled to up to 100 days of nursing home care. However, it is alleged that UnitedHealthcare has been cutting off payment for these services much sooner, often denying payment after just 14 days. The lawsuit highlights that when patient claim denials are appealed, 90 percent of the nH Predict determinations are reversed, demonstrating the inaccuracy of the algorithm.
The complaint argues that the nH Predict AI Model lacks human review and that its determinations are not communicated to patients’ doctors. When inquiries are made about coverage decisions, UnitedHealthcare employees deny requests and state that the decision information is proprietary.
UnitedHealthcare has not yet responded to the lawsuit. The case raises concerns about the use of AI algorithms in making critical healthcare decisions for vulnerable populations. The plaintiffs contend that UnitedHealthcare’s reliance on a flawed algorithm is resulting in the denial of necessary care for elderly patients. The outcome of this lawsuit will have implications for the future use of AI in healthcare insurance claims processing.
Frequently Asked Questions (FAQs) Related to the Above News
What is the lawsuit against UnitedHealthcare alleging?
The lawsuit alleges that UnitedHealthcare wrongfully denied healthcare claims using a faulty AI algorithm, resulting in the denial of medically necessary post-acute care for senior patients enrolled in their Medicare Advantage Plans.
How many people in the US rely on Medicare Advantage?
Approximately 31 million people in the US rely on Medicare Advantage.
What did the recent report from the Inspector General highlight about Medicare Advantage?
The recent report from the Inspector General highlighted that private Medicare Advantage programs deny around 13 percent of service authorization requests that would have been approved by government-run Medicare.
What is the AI system UnitedHealthcare is accused of deploying?
UnitedHealthcare is accused of deploying an AI system called the nH Predict AI Model.
What is the error rate of the nH Predict AI Model?
The lawsuit alleges that the nH Predict AI Model has an error rate of 90 percent.
How does the nH Predict AI Model override recommendations from physicians?
The nH Predict AI Model reportedly produces generic care recommendations that fail to consider individual patient needs and conflicts with Medicare Advantage coverage rules, overriding recommendations from physicians.
How has UnitedHealthcare instructed its employees regarding the algorithm's predictions?
UnitedHealthcare has allegedly instructed its employees not to deviate from the algorithm's predictions and takes disciplinary action against those who do.
What is the typical entitlement under Medicare Advantage Plans after a three-day hospital stay?
Under Medicare Advantage Plans, patients who have a three-day hospital stay are typically entitled to up to 100 days of nursing home care.
How long has UnitedHealthcare been cutting off payment for nursing home care services?
It is alleged that UnitedHealthcare has been cutting off payment for nursing home care services much sooner, often denying payment after just 14 days.
What happens when patient claim denials are appealed?
The lawsuit highlights that when patient claim denials are appealed, 90 percent of the nH Predict determinations are reversed, demonstrating the inaccuracy of the algorithm.
How does UnitedHealthcare respond to inquiries about coverage decisions?
When inquiries are made about coverage decisions, UnitedHealthcare employees allegedly deny requests and state that the decision information is proprietary.
Has UnitedHealthcare responded to the lawsuit?
No, UnitedHealthcare has not yet responded to the lawsuit.
What are the concerns raised by this lawsuit?
The lawsuit raises concerns about the use of AI algorithms in making critical healthcare decisions for vulnerable populations. It contends that UnitedHealthcare's reliance on a flawed algorithm is resulting in the denial of necessary care for elderly patients.
What are the implications of the outcome of this lawsuit?
The outcome of this lawsuit will have implications for the future use of AI in healthcare insurance claims processing.
Please note that the FAQs provided on this page are based on the news article published. While we strive to provide accurate and up-to-date information, it is always recommended to consult relevant authorities or professionals before making any decisions or taking action based on the FAQs or the news article.
