UnitedHealth Group’s ‘Flawed’ AI Model Wrongfully Denies Elderly Patients Post-Acute Care Coverage, Class Action Alleges

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UnitedHealth Group faces a proposed class action over its alleged use of a “flawed” artificial intelligence (AI) model to systemically and wrongfully deny post-acute care coverage to elderly patients with Medicare Advantage Plans.

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

The 46-page case says that rather than have a doctor determine the amount of post-acute care a patient requires to recover from serious illnesses and injuries, UnitedHealth Group and its insurance arm, UnitedHealthcare, rely on an AI algorithm known as “nH Predict” to make predictions about how much care an elderly patient “should” require. 

The defendants then make inappropriate coverage denials based on the “generic recommendations” generated by nH Predict, which fail to consider a patient’s individual needs and often contradict the basic rules governing what Medicare Advantage plans must cover, the filing claims.

For instance, patients with Medicare Advantage Plans are typically entitled to up to 100 days in a nursing home following a three-day hospital stay, the case relays. However, due to the insurance companies’ use of nH Predict, patients end up receiving payment denials about 14 days into their nursing home stays, the case alleges.

As a result, the complaint stresses, elderly patients who still require ongoing care are prematurely kicked out of care facilities or forced to pay out of pocket to continue receiving necessary medical care.

The lawsuit says that the nH Predict AI Model, which was created in 2010 by UnitedHealth subsidiary and defendant naviHealth, saves the insurance companies money by allowing them to deny claims they would have otherwise paid and cut labor costs associated with conducting individualized, manual reviews of each of their insured’s claims.

“[The defendants] also utilize the nH Predict AI Model to aggressively deny coverage because they know they will not be held accountable for wrongful denials,” the case says, claiming that the companies know only about 0.2 percent of policyholders will appeal denied claims.

According to the suit, UnitedHealth Group and UnitedHealthcare were statutorily and contractually obligated to have a real-life doctor review claims for post-acute care in a “thorough, fair, and objective manner.”

Instead, the defendants’ employees are instructed not to deviate from nH Predict’s “rigid and unrealistic” predictions about patients’ medical needs, estimated length of stay and target discharge date, which are generated by comparing data about a patient’s diagnosis, age, living situation and physical function to that of similar patients within its database, the filing alleges.

“The employees who deviate from the nH Predict AI Model prediction are disciplined and terminated, regardless of whether the additional care for a patient is justified,” the case claims.

The complaint contends that the defendants’ reliance on the nH Predict AI Model has resulted in a substantial rise in the number of post-acute care coverage denials. Per the suit, the high rate at which these decisions are reversed through an internal appeal process or federal administrative law judge proceedings demonstrates “the blatant inaccuracy of the nH Predict AI Model and the lack of human review involved in the coverage denial process.”

The lawsuit looks to represent anyone in the United States who purchased Medicare Advantage Plan health insurance from UnitedHealth Group or UnitedHealthcare within the past four years.

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