The report revealed that UnitedHealthcare approved using "Machine Assisted Prior Authorization" in April 2021 to expedite medical request reviews, which led to faster processing but also more denials due to error detection. In December 2022, the company explored using AI to predict appeal outcomes for denied cases. In November 2023, UnitedHealthcare faced a class-action lawsuit accusing it and its subsidiary, NaviHealth, of using an algorithm to systematically deny claims for Medicare beneficiaries in nursing homes, allegedly overriding physicians’ determinations and knowing the AI model had a 90% error rate. The lawsuit argued that the company relied on the low appeal rate of denied claims to continue using the flawed AI model.
Key takeaways:
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- Democrats on a Senate subcommittee accused UnitedHealthcare of increasing claim denials by leveraging artificial intelligence to automate the process, with denial rates for post-acute care rising significantly from 2020 to 2022.
- UnitedHealthcare faced criticism for allegedly prioritizing less costly home health services over post-acute care facilities, as highlighted in a Senate report.
- A class-action lawsuit was filed against UnitedHealthcare and its subsidiary, NaviHealth, accusing them of using AI to systematically deny claims for Medicare beneficiaries, despite a high error rate in the AI model.
- The lawsuit claims that UnitedHealthcare relies on the low likelihood of appeals from policyholders to continue using the flawed AI model, which allegedly overrides treating physicians' determinations.