Class Action Lawsuit Claims UnitedHealth’s AI Systematically Denied Extended Care to Seniors
UnitedHealth Group, the largest health insurance provider in the United States, is facing a potential class action lawsuit that alleges the company’s use of an artificial intelligence (AI) algorithm systematically denied elderly patients’ claims for extended care. The lawsuit, filed in Minnesota federal court, was made on behalf of the family members of two deceased UnitedHealth beneficiaries who claim they were forced to pay out of pocket for medically necessary care due to claim denials by the insurer. The plaintiffs’ lawyers aim to represent a nationwide class of individuals on Medicare Advantage insurance plans, typically funded by Centers for Medicare & Medicaid Services (CMS) programs but administered by private health insurers like UnitedHealth.
5 Key Points
- UnitedHealth is facing a potential class action lawsuit over using an AI algorithm called nH Predict, which allegedly denied elderly patients’ claims for extended care.
- The algorithm, developed by NaviHealth, a company acquired by UnitedHealth in 2020, is reportedly used to assess claims for post-acute care, including stays in skilled nursing facilities and in-home care.
- The lawsuit claims that UnitedHealth used the algorithm to prematurely and in bad faith discontinue payment for healthcare services, with approximately 90% of denials being reversed when appealed to federal administrative law judges.
- The plaintiffs seek a court order to stop the practice and award damages, arguing that using nH Predict violates contracts with patients and insurance laws in various states.
- UnitedHealth denies the allegations, stating that the NaviHealth Predict tool is not used to make coverage determinations and that the lawsuit has no merit.
The Controversial nH Predict algorithm
At the center of the lawsuit is an AI algorithm called nH Predict, developed by NaviHealth, a company acquired by UnitedHealth in 2020. The insurer allegedly uses the algorithm to assess claims for post-acute care, including stays in skilled nursing facilities and in-home care. According to the complaint, UnitedHealth used the algorithm to prematurely and in lousy faith discontinue payment for healthcare services. The plaintiffs argue that when these denials are appealed to federal administrative law judges, approximately 90% are reversed, highlighting the alleged blatant inaccuracy of the algorithm. Despite these concerns, court documents indicate that UnitedHealth still uses AI.
Families Seek Justice for Denied Care
The filing in Minnesota federal court was made on behalf of the family members of two deceased UnitedHealth beneficiaries, with both families claiming they were forced to pay out of pocket for medically necessary care due to claim denials by the insurer. The lawsuit contends that the use of nH Predict violates contracts with patients and insurance laws in various states, and thus, the plaintiffs are seeking a court order to stop the practice and award damages. The plaintiffs’ lawyers aim to represent a nationwide class of individuals on Medicare Advantage insurance plans, typically funded by Centers for Medicare & Medicaid Services (CMS) programs but administered by private health insurers like UnitedHealth.
UnitedHealth Denies Allegations, Vows to Defend Itself
In response to the lawsuit, UnitedHealthcare stated HealthExec, denying the allegations and asserting that the NaviHealth Predict tool is not used to make coverage determinations. The company
said, “The tool is used as a guide to help us inform providers, families, and other caregivers about what sort of assistance and care the patient may need both in the facility and after returning home. Coverage decisions are based on CMS coverage criteria and the terms of the member’s plan.” UnitedHealth maintains that the lawsuit has no merit and vows to vigorously defend itself. It still needs to be determined if the lawsuit will be settled out of court, and no trial date is currently set, as the suit is still seeking class-action status.
FAQ
Q. Do you qualify for a Malpractice lawsuit?
A. To see if you qualify, click here.
Q. What is the nH Predict algorithm, and who developed it?
A. nH Predict is an AI algorithm developed by NaviHealth, a company acquired by UnitedHealth in 2020. The insurer allegedly uses the algorithm to assess claims for post-acute care, including stays in skilled nursing facilities and in-home care.
Q. What are the main allegations in the lawsuit against UnitedHealth?
A. The lawsuit alleges that UnitedHealth used the nH Predict algorithm to systematically deny elderly patients’ claims for extended care, forcing families to pay out of pocket for medically necessary care. The plaintiffs argue that the algorithm’s use violates contracts with patients and insurance laws in various states.
Q. Who filed the lawsuit against UnitedHealth, and who do they aim to represent?
A. The filing in Minnesota federal court was made on behalf of the family members of two deceased UnitedHealth beneficiaries. The plaintiffs’ lawyers aim to represent a nationwide class of individuals on Medicare Advantage insurance plans, typically funded by CMS programs but administered by private health insurers like UnitedHealth.
Q. What does UnitedHealth say about the allegations?
A. UnitedHealth denies the allegations, stating that the NaviHealth Predict tool is not used to make coverage determinations and that the lawsuit has no merit. The company vows to defend itself vigorously.
Q. What is the lawsuit’s current status, and is there a trial date set?
A. It still needs to be clarified if the lawsuit will be settled out of court, and no trial date is currently set, as the suit is still seeking class-action status.
Citations:
Van Alstin, C. (2023, November 15). UnitedHealth faces lawsuit over AI algorithm that allegedly denied care to elderly patients. HealthExec. https://healthexec.com/topics/healthcare-management/healthcare-policy/unitedhealth-lawsuit-ai-medicare-advantage?utm_source=related_content&utm_medium=related_content&utm_campaign=related_content
