The nation’s largest insurer is illegally using programs driven by artificial intelligence to override the decisions of medical professionals and wrongfully force residents from nursing homes, a lawsuit seeking class-action status claims.
A lawyer representing the plaintiffs told Reuters that the class, if certified by the court, could include tens of thousands of plaintiffs, and that claims for damages could reach billions of dollars.
The case is being brought by the estates of Gene B. Lokken and Dale Henry Tetzloff, both Medicare Advantage beneficiaries whose coverage for skilled nursing care abruptly was cut off just days into their stays. Doctors overseeing their treatment insisted that they needed further in-patient services, but both cases were denied on appeal. Each family paid for months of continued SNF care out-of-pocket until both men died earlier this year.
In documents filed Tuesday in US District Court in Minnesota, attorneys argued that the post-acute care coverage was wrongfully terminated by UnitedHealthcare using its nH Predict AI Model.
“Defendants failed to use reasonable standards in evaluating the individual claims of plaintiffs and class members and instead allowed their coverage needs to be wholly determined by AI,” they wrote.
Insurers have been under increasing scrutiny as the use of AI in patient-facing decisions becomes more apparent. Congress has held hearings on denial patterns, and STAT News on Wednesday released its latest investigation into the issue. It cited former UnitedHealthcare employees who said that claims denials were aligned with algorithm-based calculations by design, even when it came to discontinuing coverage for seriously ill patients.
The Centers for Medicare & Medicaid Services has instituted several limitations on how MA insurers can deny care in the future, but those changes don’t kick in until Jan. 1. Experts also have said they are uncertain whether the updated MA rule will have enough bite to prompt real change by plans.
Only about 10% of claims ever are appealed by residents. The risk of losing the appeal and being held financially responsible for a lengthier stay — such as was the case for the plaintiffs — continues to discourage requests for review.
“Defendants bank on the patients’ impaired conditions, lack of knowledge and lack of resources to appeal the erroneous AI-powered decisions,” plaintiff attorneys wrote.
UnitedHealthcare did not immediately respond to McKnight’s Long-Term Care News’ request for comment, but the company previously has said that the case is without merit.
