Elderly Patients Wrongfully Denied Coverage by Humana’s AI Algorithm, Class Action Claims

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A proposed class action alleges Humana’s use of an artificial intelligence (AI) model to predict insureds’ healthcare needs has caused elderly patients to be wrongfully denied the post-acute care coverage owed to them under their Medicare Advantage plans.

If you or a family member has a Humana Medicare Advantage plan and had post-hospital care cut short, let us know here.

According to the 44-page lawsuit, the insurance company utilizes an AI model known as nH Predict, which attempts to calculate the amount of medically necessary care a patient recovering from serious illness or injury “should” require and, thus, determine when Humana may cut off payment for their treatment.

However, the suit claims the insurer wrongfully relies on the AI algorithm and uses it to override real doctors’ recommendations and prematurely end payment for medical services for elderly patients still in need of post-acute care coverage.

“Humana knows that the nH Predict AI Model predictions are highly inaccurate and are not based on patients’ medical needs but continues to use this system to deny patients’ coverage,” the case contends, adding that elderly patients are then left to choose between devastating medical debt or foregoing the care they need.

The complaint charges that nH Predict “spits out generic recommendations based on incomplete and inadequate medical records” without taking into account a patient’s individual circumstances. The AI model determines coverage terms with “rigid and unrealistic predictions for recovery” and often makes recommendations that “conflict with basic rules on what Medicare Advantage plans must cover,” the filing alleges.

Because Humana determines coverage based on the algorithm’s predictions, rather than on an individual’s needs or their doctor’s prescriptions, the number of post-acute care coverage denials has increased substantially, the lawsuit claims.

By way of example, patients with Medicare Advantage plans who have a three-day stay in the hospital are usually entitled to up to 100 days in a nursing home, the suit says. However, the case relays that since Humana began using nH Predict, insureds “rarely stay in a nursing home more than 14 days before they start receiving payment denials.”

The insurer’s use of the AI model to prematurely discontinue coverage without regard to individual needs is “systematic, illegal, malicious, and oppressive,” the complaint contends.

“Humana has deliberately failed to fulfill its statutory, common law, and contractual obligations to have a doctor determine individual coverage for post-acute care in a thorough, fair, and objective manner, instead using the nH Predict AI Model to supplant real doctors’ recommendations and patients’ medical needs,” the filing argues.

As the lawsuit tells it, relying on the algorithm benefits Humana financially by allowing it to deny coverage claims it would otherwise have to pay, to the detriment of patients across the country.

“The fraudulent scheme affords Humana a clear financial windfall in the form of policy premiums without having to pay for promised care, while the elderly are prematurely kicked out of care facilities nationwide, forced to deplete family savings to continue receiving necessary medical care, or forced to forgo care altogether, all because an AI Model ‘disagrees’ with their real live doctors’ determinations,” the suit charges.

The plaintiffs, two women who claim their post-acute care coverage was wrongfully terminated by Humana, have been forced to pay staggering out-of-pocket costs for medically necessary treatment that should have been covered by their Medicare Advantage plans, the case alleges.

The lawsuit looks to represent anyone in the United States who purchased Medicare Advantage health insurance from Humana at any time in the past four years.

If you or a family member has a Humana Medicare Advantage plan and had post-hospital care cut short, let us know here.