The lawsuit and an investigation by Stat News suggest that the algorithm's estimates often result in patients being denied coverage for necessary care. UnitedHealth has reportedly denied requests to see nH Predict's reports, claiming the information is proprietary. The lawsuit also seeks class-action status for similarly situated people, potentially affecting tens of thousands across the country.
Key takeaways:
- UnitedHealthcare, the largest health insurance company in the US, is allegedly using a flawed AI algorithm to override doctors' judgments and wrongfully deny critical health coverage to elderly patients, according to a lawsuit filed in the US District Court for the District of Minnesota.
- The AI algorithm, called nH Predict, estimates how much post-acute care a patient on a Medicare Advantage Plan will need after an acute injury, illness, or event, but it reportedly doesn't account for many relevant factors in a patient's health and recovery time.
- Patients who stay in a hospital for three days are typically entitled to up to 100 days of covered care in a nursing home, but with nH Predict, patients rarely stay in nursing homes for more than 14 days before receiving payment denials from UnitedHealth.
- Since UnitedHealth acquired NaviHealth in 2020, the company's focus shifted from patient advocacy to performance metrics and keeping post-acute care as short and lean as possible, according to former employees.