Nearly every industry is trying to learn how artificial intelligence (AI) can improve workflow and profits. As the technology quickly develops there are bound to be conflicts.
One such conflict has arisen in a lawsuit filed against UnitedHealthcare. The plaintiffs – the estates of two elderly men who recently died – claim the health insurance giant used AI to review their relatives’ claims and to wrongly deny them.
The complaint, filed in federal court in Minneapolis, claims UnitedHealth wrongfully denied claims filed by the two patients, both of whom had Medicare Advantage Plans. As a result, the two families said they were forced to pay $210,000 for the men to receive treatment ordered by their doctors.
The plaintiffs contend that UnitedHealth began routinely denying these types of claims in 2020 when it acquired Navihealth, a company that provides post-acute care management services.
STAT News Investigation
A recent investigation by STAT News reported that Navihealth uses a computer algorithm to predict the length of treatment required for acute illnesses and injuries, such as those treatments provided in rehab centers and nursing homes. According to the investigation, the algorithm makes its predictions by accessing 6 million similar cases.
The plaintiffs further contend that the algorithm is prone to mistakes. In fact, the complaint claims the AI tool overrules patients’ physicians 90% of the time. Many times, the plaintiffs say, the denials have been overruled on appeal.
UnitedHealth denies the claims made in the lawsuit. Optum Health, a UnitedHealth subsidiary, released a statement to Ars Technica saying the tool is not used to make coverage decisions.
“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,” a spokesperson said. “Coverage decisions are based on CMS coverage criteria and the terms of the member's plan. This lawsuit has no merit, and we will defend ourselves vigorously."
Photo Credit: Consumer Affairs News Department Images
Posted: 2023-11-21 11:46:02
