According to a newly filed lawsuit, Humana exploited AI algorithms to deny important rehabilitation services to the elderly. In this case, the plaintiffs have made comparable accusations against UnitedHealthcare, another major participant in the Medicare Advantage program. The plaintiffs claim that the insurer used naviHealth’s nH Predict program to determine long-term care coverage.
The company, which UnitedHealth Group’s Optum currently owns, is also the target of litigation filed against UHC. According to the lawsuit, the nH Predict algorithm predicts how long a patient would require rehabilitative therapy according to “rigid and unrealistic predictions for recovery.”
“As such, Humana makes coverage determinations not based on individual patient’s needs, but based on the outputs of the nH Predict AI Model, resulting in the inappropriate denial of necessary care prescribed by the patient’s doctors,” according to the lawsuit filed by the plaintiffs. “Humana’s implementation of the nH Predict AI Model resulted in a significant increase in the number of post-acute care coverage denials.” According to a Humana representative, the insurance is not commenting on ongoing lawsuits.
In addition to calling the algorithm’s methodology into doubt, the lawsuit claims that employees were under pressure to meet the model’s expectations, risking suspension or termination if they did not. Two plaintiffs filed the action, but they estimate that the affected class might “number in the thousands to millions.”
After being hospitalized in November 2021 due to a fall, one of the plaintiffs, JoAnne Barrows, who is 86 years old, was released to a rehabilitation center. According to the lawsuit, she was placed on a non-weight-bearing restriction for six weeks owing to a leg injury.
Legal documents show that Humana notified Barrows that her coverage would be terminated after only two weeks of rehabilitation, even though she was supposed to remain non-weight-bearing for an extra month. According to the lawsuit, she appealed the judgment but was denied, leaving the family to pay for her recovery out of pocket. A lawsuit filed against UnitedHealth last month claimed that naviHealth’s software displays a “90% error rate”. It stated that the insurer used it despite this since very few members challenge claim denials.
