As the healthcare industry has begun to use artificial intelligence (AI) algorithms in its claims determination process, litigation has ensued. In a recent class action lawsuit, plaintiffs claim that UnitedHealthcare used its “nH Predict” AI algorithm to wrongfully deny elderly patients’ claims for post-acute care, including stays in skilled nursing-care facilities and in-home care. When patients appeal the denials of coverage to federal administrative law judges, about 90% of the denials are reversed.
The UnitedHealthcare lawsuit follows a similar lawsuit against health insurance company Cigna earlier this year. In that lawsuit, plaintiffs allege that Cigna used AI to automatically deny patient claims without opening their files.
The named plaintiffs in the lawsuit are the estates of deceased individuals who formerly were covered by Medicare Advantage plans provided by UnitedHealthcare. The insurance giant denied each of the plaintiffs’ coverage for at least a portion of their stay in extended care facilities. These patients continued paying for care at an extended-care facility after UnitedHealthcare denied coverage, costing tens of thousands of dollars annually.
In the lawsuit, the plaintiffs claim that UnitedHealthcare’s use of nH Predict violates their contracts with the insurance company, as well as the insurance laws of various states, by deciding claims without properly evaluating them. The plaintiffs seek a court order prohibiting UnitedHealthcare from engaging in this practice and an award of monetary damages.
UnitedHealthcare alleges that its nH Predict tool was not used to make claim determinations. Instead, it claims that it used the AI tool as a guide to inform providers, families, and caregivers about the assistance and care a patient may need while in a facility and after returning home. The insurer argues that it continues to make coverage decisions based on Medicare coverage criteria and the terms of the insured’s plan.
The case is Estate of Gene. B. Lokken v. UnitedHealth Group, Inc., D. Minn., No. 23-cv-03514.
