Published on November 17, 2023, 4:58 am

“Flawed Ai Algorithm Allegedly Used By Unitedhealthcare To Deny Health Coverage To Elderly Patients”

UnitedHealthcare, the largest health insurance company in the US, is facing allegations that it is using a flawed AI algorithm to wrongfully deny critical health coverage to elderly patients. This has resulted in patients being prematurely discharged from rehabilitation programs and care facilities, causing them to deplete their life savings in order to obtain the necessary care that should be covered under their Medicare Advantage Plan.

According to a lawsuit filed in the US District Court for the District of Minnesota, UnitedHealth allegedly denied health coverage to two deceased individuals. The lawsuit also seeks class-action status for others who may have experienced similar denials, which could potentially involve tens of thousands of people across the country.

Backing these claims are findings from an investigation by Stat News, which obtained internal documents, communications, and interviewed former employees of NaviHealth – the UnitedHealth subsidiary responsible for developing the AI algorithm known as nH Predict. One former employee stated that she realized she was simply a “moneymaker” for the company and expressed her dislike for how the algorithm disregards patient dignity.

The nH Predict algorithm has reportedly been in use since November 2019 and estimates post-acute care needs for Medicare Advantage Plan patients following an acute injury or illness. It draws information from a database containing medical cases from 6 million patients and generates estimates based on similar cases. However, it fails to account for relevant factors such as comorbidities or additional health complications that may arise during hospital stays or nursing home placement.

The investigation and lawsuit reveal that nH Predict’s estimates often lead to denied payments and short stays at nursing homes – contrary to what patients on a Medicare Advantage Plan are entitled to. When patients or their doctors have requested access to nH Predict’s reports, UnitedHealth has allegedly denied their requests on proprietary grounds. Additionally, if prescribing physicians disagree with UnitedHealth’s determination of post-acute care needs, their judgments are overruled.

While faulty AI use is not new to the healthcare industry, this particular situation stands out due to UnitedHealth’s apparent focus on keeping post-acute care as short and lean as possible since acquiring NaviHealth in 2020. Former employees highlighted a shift from patient advocacy to performance metrics within the company. Statements made by UnitedHealth executives also seemed to emphasize the goal of minimizing nursing home stays.

This case raises concerns about the larger issue of problematic AI use in healthcare, which extends beyond chatbots and image generators. In this instance, it appears that UnitedHealth’s AI algorithm may be intentionally producing dubious estimates rather than being an unintentional flaw.

As more details emerge from this lawsuit and investigation, it remains to be seen how UnitedHealth will address these allegations and whether any changes will be implemented to ensure fair and accurate coverage determination for elderly patients under their Medicare Advantage Plan.


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