Humana sued for allegedly using AI for Medicare Advantage denials
The lawsuit accuses Humana of cutting payments prematurely for rehabilitative care based on its AI model's "highly inaccurate" recovery predictions.
Photo: Pichsakul Promrungsee EyeEm/Getty Images
Humana has become the latest insurer to be sued over allegedly using artificial intelligence to deny care, with a class action lawsuit claiming the company's nH Predict AI model was used to deny care to Medicare Advantage members.
The lawsuit accuses Humana of cutting payments prematurely for rehabilitative care based on nH Predict's "highly inaccurate" recovery predictions, favoring them over doctors' recommendations.
nH Predict was developed by UnitedHealth Group subsidiary NaviHealth, which the former acquired in 2020. UnitedHealth Group is the target of another, and very similar, class action lawsuit filed last month. One of the allegations in that suit is that UnitedHealth uses nH Predict to evaluate claims for post-acute care, including in-home care and extended stays in skilled nursing facilities, and that the company uses the algorithm to "prematurely and in bad faith" halt payments for healthcare services.
The AI model is designed to predict length of stay in skilled nursing facilities, but the new Humana lawsuit alleges the algorithm has a high rate of error. It claims patients were forced to prematurely end their care or dig into savings to afford care after claims were denied.
The lawsuit also claims that only about 2% of Humana customers appealed denied claims – a low rate of appeals that plaintiffs say is of benefit to Humana.
Humana did not immediately respond to a request for comment.
THE LARGER TREND
In July, Cigna was sued for allegedly using algorithms to deny claims.
The lawsuit, filed in federal court in California, claimed Cigna developed an algorithm known as PXDX to enable its doctors to automatically deny payments in batches of hundreds or thousands at a time for treatments that did not match certain preset criteria.
A Cigna Healthcare spokesperson, responding by statement, said the vast majority of claims reviewed through PXDX are automatically paid and that the process does not involve algorithms, AI or machine learning, but a simple sorting technology that has been used for more than a decade to match up codes.
UnitedHealth faced another lawsuit in June over allegedly denying claims. The U.S. Department of Labor brought the lawsuit against UnitedHealth Group subsidiary UMR, claiming it incorrectly denied emergency room and urinary drug screening claims for thousands of patients, thereby failing to comply with the requirements of the Affordable Care Act and the DOL's claims procedures regulation.
According to that complaint, UMR is UHG's third-party administrator, providing benefits services to more than 2,000 self-funded employer health plans.
Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com
