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UHC Insurance sued over alleged faulty AI denying Medical claims

 A class-action lawsuit against UnitedHealth Group, based in Minnetonka, was filed on Tuesday. It claims the company improperly used a flawed artificial intelligence algorithm to refuse Medicare patients who needed rehabilitation care after being hospitalized. The lawsuit was submitted to the U.S. District Court for the District of Minnesota following an examination by the news website STAT, which revealed the company’s use of this contentious technology.

The primary plaintiffs, who are the families of two patients from north-central Wisconsin, which is located around three hours east of the Twin Cities, assert that they had to pay a substantial amount of money out of pocket when UnitedHealth Group rejected their requests for post-acute care.

UnitedHealth Group has fiercely refuted the allegations, claiming that the complaint “has no merit” and announcing that it will provide a strong defense.

According to the lawsuit, the health insurance used artificial intelligence (AI) instead of medical professionals, allegedly deploying an AI model with a 90% mistake rate to override treating physicians’ decisions about what medically essential therapy was.

UnitedHealth Group responded to the allegations by stating that it does not use the technologies used in the lawsuit to determine coverage. According to the firm, the tool serves as a guide to educate caregivers, families, and providers on the kinds of support and care that a patient could need while they are in a facility and when they go back home. The statement states that coverage determinations are made in accordance with the member’s plan terms and federal coverage criteria.

UnitedHealth Group, a major health insurer in the US, is headquartered in Minnetonka and runs UnitedHealthcare. It is also the top supplier of Medicare Advantage plans. According to the lawsuit, plaintiffs have had to spend up to $70,000 in out-of-pocket expenses as a result of the claims’ denial, making them financially responsible for their own ongoing care.

Additionally, according to the lawsuit, UnitedHealth Group forbids its staff members from straying from the AI projections, and non-compliance has disciplinary consequences, including termination. As per the lawsuit, this allegedly rigid system prioritizes profits over the welfare of senior citizens, resulting in early release from assisted living facilities or pressuring families to spend all of their savings on essential medical care because AI models and actual physicians’ opinions diverge.

A wider trend of growing skepticism among consumers and the government about health insurers refusing to pay for medically necessary services is being highlighted by this lawsuit. The criticism of artificial intelligence in healthcare decision-making and its possible effects on patients caught in the crossfire are highlighted by UnitedHealth Group’s statement.

The lawsuit against UnitedHealth Group claims that in spite of its flaws, the business continues to use an AI model called “nH Predict.” Based on the complaint, the corporation projects recovery timeframes in facilities such as nursing homes and uses this technology to evaluate and reject claims for post-acute care.

The lawsuit alleges that because so few individuals usually file appeals against health insurance denials, UnitedHealth Group has been using the flawed AI model for an extended period of time. The lawsuit’s plaintiffs tried to challenge the company’s rulings, but they were unable to do so and had to make the payment themselves. The complaint states that because appealing denials can be difficult, patients sometimes decide not to pursue the rest of their post-acute care prescription.

The complaint included an example report from NaviHealth, a business UnitedHealth Group bought in May 2020 from a Tennessee-based firm. The “nH Predict” model evaluates a patient’s mobility, degree of activity, and cognitive scores to provide a report that forecasts how long the patient will remain in a skilled nursing facility. Plaintiffs contend that in order to challenge AI-powered choices, UnitedHealth Group exploits patients’ compromised health, ignorance, and lack of finances.

This lawsuit comes after a number of other recent UnitedHealth Group-related scandals. The U.S. Department of Labor filed a complaint in July against a subsidiary of UnitedHealth Group, claiming that thousands of claims for drug tests and ER treatments had been wrongfully denied by healthcare providers. The business recognized that the allegation concerned administrative procedures even as it defended its methods.

Furthermore, last month, UnitedHealth Group subsidiary Bright Health, located in Bloomington, was fined $1 million by Nebraska authorities for processing claims incorrectly in more than 100 instances, including some where coverage for newborn medical treatment was refused.

The lawsuit filed against UnitedHealth Group heightens the attention being paid to the denial methods used by the health insurance sector. In the previous year, the U.S. Department of Health and Human Services’ Office of Inspector General conducted a review that found that roughly 13% of prior authorization requests denied by Medicare Advantage plans were in compliance with coverage guidelines and probably ought to have been covered by original Medicare. These occurrences highlight worries about how AI-driven decision-making may affect patient care and the necessity of tighter regulation in the health insurance industry.




Editorial Staff
Editorial Staff
Editorial Staff at AI Surge is a dedicated team of experts led by Paul Robins, boasting a combined experience of over 7 years in Computer Science, AI, emerging technologies, and online publishing. Our commitment is to bring you authoritative insights into the forefront of artificial intelligence.


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