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Humana Used AI Tool from UnitedHealth to Deny Medicare Advantage Claims
Humana used an artificial intelligence tool owned by UnitedHealth Group to wrongfully deny Medicare Advantage [Part C] members’ medical claims, according to a class-action complaint filed on Dec. 12th. The lawsuit was filed in the U.S. District Court for the Western District of Kentucky and is the latest legal action against major insurers such as UnitedHealthcare and Cigna for allegedly using automated data tools to wrongfully deny members’ claims.
The complaint against Humana, the country’s second-largest Medicare Advantage insurer, accuses the company of using an AI tool called nH Predict to determine how long a patient will need to remain in post-acute care and overrides physicians’ determinations for the patient. The plaintiffs claim Humana set a goal to keep post-acute facility stay lengths for MA members within 1% of nH Predict’s estimations. Employees who deviate from the algorithm’s estimates are “disciplined and terminated, regardless of whether a patient requires more care,” the lawsuit alleges. When decisions made by the algorithm are appealed, they are allegedly overturned 90% of the time.
Source: Jakob Emerson Becker’s Payer Issues [12/13/23]
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Filed under: "Doctors Only", Ethics, Experts Invited, Health Insurance, Health Law & Policy, Insurance Matters | Tagged: Becker's Payer Issues, c, Cigna, Humana, Jakob Emerson, MA, Medicare Advantage, nH Predict, Part C, uch, United Health Group, UnitedHealth | 1 Comment »
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