Lawsuit Investigation: Did an Algorithm Deny Your Medicare Advantage Claim?

Last Updated on September 23, 2024

At A Glance

This Alert Affects:: Medicare Advantage plan policyholders whose insurer ended coverage prematurely for care that was needed following a hospital stay. This may have included care from home health agencies, skilled nursing facilities, inpatient rehab centers or long-term care hospitals.
What’s Going On?: Concerns are growing that some health insurance companies may be using predictions from a faulty, profit-driven AI tool – over doctor recommendations – to decide how long patients need rehabilitative care, often resulting in coverage being cut off too soon. Attorneys are now looking into a number of insurance providers and need to hear from policyholders, as well as family members acting on their behalf, who’ve had this happen to them. The attorneys may be able to get class action lawsuits on file.
Which Insurance Providers Are Under Investigation?: UnitedHealthcare, Humana and BlueCross BlueShield
What You Can Do: If you or a family member had to go out of pocket or end rehabilitative care early because a UnitedHealthcare (sometimes branded as AARP), Humana or BlueCross BlueShield Medicare Advantage plan would no longer cover it, fill out the form on this page to learn more.
How a Lawsuit Could Help: A successful class action could give patients some money back for premiums and out-of-pocket costs. A lawsuit could also force the health insurer to change the way it uses AI in determining coverage.

Attorneys working with ClassAction.org are investigating whether they can file class action lawsuits against UnitedHealthcare, Humana and BlueCross BlueShield over the use of AI tools in determining certain coverage limits for Medicare Advantage customers.

Concerns have surfaced that some health insurance companies may be using a flawed algorithm to determine how soon they can feasibly cut off care for seniors who need additional recovery time following a hospital stay (known as post-acute care), rather than basing this decision on doctors’ recommendations and individual patient needs.

This means patients could be getting kicked out of skilled nursing facilities, inpatient rehab centers and long-term care hospitals well before they should or left with no choice but to drain their savings to continue care that their doctors deemed medically necessary.

Both UnitedHealthcare and Humana have been hit with proposed class action lawsuits alleging they wielded profit-driven and faulty AI called “nH Predict” to deny necessary rehabilitative care to their Medicare Advantage customers. Now, attorneys are working to determine whether they can get additional cases on file, potentially including a new lawsuit on behalf of BlueCross Blue Shield policyholders.

As part of their investigation, attorneys would like to speak with anyone who meets the following criteria (as well as family members acting on their behalf):

Had a UnitedHealthcare, AARP (which may have been offered through UnitedHealthcare), Humana or BlueCross BlueShield Medicare Advantage plan
Had post-hospital care terminated early or had their claim denied despite their doctor recommending continued care

To help this investigation and share your story, fill out the form on this page. After you get in touch, an attorney or legal representative may reach out to you directly to explain more.

UnitedHealthcare Scandal

In mid-November 2023, an investigative report from health and medicine news publication STAT revealed that UnitedHealthcare was not only cutting short Medicare Advantage patients’ care based on a computer algorithm’s predictions, but also threatening termination or other repercussions for staff who didn’t follow the tool’s recommendations.

Specifically, STAT reported that naviHealth, a subsidiary of UnitedHealth and creator of the AI tool nH Predict, set a target for 2023 to keep patients’ rehab stays “within 1% of the days projected by the algorithm.” According to the article, some case managers felt that deciding whether to push for more care or recommend a denial “too often meant choosing between their job performance and their conscience.”

As an example, the authors shared one case in which an older woman who suffered a stroke was allowed only 20 days of rehabilitative care even though “the average for severely impaired stroke patients is almost double that.”

The same day the STAT article was published, a proposed class action lawsuit was filed alleging UnitedHealthcare, UnitedHealth Group, and naviHealth, Inc. are illegally deploying artificial intelligence, know most patients won’t appeal their erroneous coverage decisions, and are engaging in a “fraudulent scheme” that affords the companies a “clear financial windfall.”

The 2023 UnitedHealthcare lawsuit also claims that the company knows its AI tool has a 90 percent error rate yet continues to use it to systematically deny claims.

In light of these allegations, attorneys working with ClassAction.org would like to hear from patients (or their families) in California, Florida, Texas or New York who had post-hospital care denied under any of the following plans:

UnitedHealthcare Medicare Advantage
UnitedHealthcare Medicare Advantage Assure
UnitedHealthcare Medicare Advantage Choice
UnitedHealthcare Medicare Advantage Focus
UnitedHealthcare Medicare Advantage Patriot
UnitedHealthcare Dual Complete
AARP Medicare Advantage Plan
AARP Medicare Advantage Choice
AARP Medicare Advantage Secure Horizons
AARP Medicare Advantage Rebate
AARP Medicare Advantage Harmony
AARP Medicare Advantage Freedom Plus
AARP Medicare Advantage Patriot

AARP-branded Medicare insurance products are offered by UnitedHealthcare, which is why they are included above.

UnitedHealthcare previously faced class action lawsuits in 2017 and 2018 alleging, respectively, that the company unfairly reduced benefits for out-of-network mental healthcare and tricked senior citizens and disabled individuals into paying artificially inflated prices for Medicare supplemental health insurance policies.

Humana Medicare AI Controversy

A month after UnitedHealthcare was sued, Humana was hit with a similar lawsuit over its own use of nH Predict.

Humana was accused of working with naviHealth to set the same target of keeping stays at skilled nursing facilities, rehab centers and the like within one percent of the days predicted by the algorithm. According to the case, Humana employees who deviate from nH Predict’s recommendations are “disciplined and terminated, regardless of whether a patient requires more care.”

Ultimately, the case alleges that the AI tool set “rigid and unrealistic predictions for recovery” and caused a “significant increase” in the number of patients who were denied coverage for post-hospital care.

In light of these claims, attorneys working with ClassAction.org would like to hear from patients (or their family members) who had post-hospital care cut short and had one of the following Humana Medicare Advantage Plans:

Humana Gold Plus HMO
HumanaChoice Medicare Advantage PPO
Humana USAA Honor PPO

BlueCross BlueShield

Following reports of AI driving health insurers’ denials to “new heights” and the proposed class actions detailed above, attorneys working with ClassAction.org are also investigating whether BlueCross BlueShield is using an algorithm to improperly deny certain coverage for Medicare Advantage customers.

As part of their investigation, they would like to hear from patients (or their family members) who had a BlueCross Blue Shield Medicare Advantage plan, including those sold under Anthem, Highmark and Empire branding, and feel coverage for post-hospital care was cut too short.

It’s possible that BlueCross BlueShield could face a lawsuit similar to those brought against UnitedHealthcare and Humana over Medicare Advantage coverage denials.

How Could a Lawsuit Help Medicare Advantage Patients?

If successful, class action lawsuits could result in patients recovering some of the money they paid in premiums and potentially some of the out-of-pocket costs incurred after coverage was denied.

A successful case could also force the health insurance company being sued to change the way artificial intelligence is used in making coverage decisions.

If you or your family member had post-hospital care cut short under a UnitedHealthcare, Humana or BlueCross Blue Shield Medicare Advantage plan, fill out the form on this page. You may be able to take legal action against the insurance company. It doesn’t cost anything to get in touch or to speak to someone about your rights.

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