News Briefs: Suit Accuses UnitedHealth of Using AI to Wrongfully Deny MA Care

November 16

In a proposed class action lawsuit filed in the U.S. District Court of Minnesota, UnitedHealth Group and its subsidiary, NaviHealth, are accused of using an artificial intelligence algorithm with a known error rate of 90% to systematically deny Medicare Advantage enrollees’ care. The lawsuit, filed by the estates of two deceased patients who were enrolled in a UnitedHealthcare MA plan and “on behalf of all others similarly situated,” alleges that the insurer continued to use its AI model to “wrongfully deny” and override physicians’ recommendations for post-acute care “because they know that only a tiny minority of policyholders (roughly 0.2%) will appeal claims, and the vast majority will either pay out-of-pocket costs or forgo the remainer of their prescribed post-acute care,” according to the complaint posted by STAT. The complaint follows and cites a STAT investigation of internal documents showing that NaviHealth employees were pressured to keep MA patients’ skilled nursing facility stays to targets developed by the nH Predict algorithm, or they would face disciplinary action. In a statement provided to STAT, UnitedHealth asserted that the NaviHealth tool is “used as a guide” but does not make coverage determinations.

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Radar on Medicare Advantage

Lauren Flynn Kelly Managing Editor, Radar on Medicare Advantage

Lauren has been covering health business issues since the early 2000s and specializes in in-depth reporting on Medicare Advantage, managed Medicaid and Medicare Part D. She also possesses a deep understanding of the complex world of pharmacy benefit management, having written AIS Health’s Radar on Drug Benefits from 2004 to 2005 and again from 2011 to 2016. In addition to her role as managing editor of Radar on Medicare Advantage, she oversees AIS Health’s publications and manages the health editorial staff. She graduated from Vassar College with a B.A. in English.