UnitedHealth’s nH Predict AI Faces Legal Backlash

UnitedHealthcare, the foremost health insurance company in the US, is under lawsuit for utilizing a flawed AI algorithm, nH Predict, to deny crucial health coverage to elderly patients.

A recent lawsuit filed in the US District Court for the District of Minnesota unveils disturbing practices that allegedly override doctors’ decisions, leaving patients prematurely ejected from vital rehabilitation programs.

Allegations and Investigations:

The lawsuit was initiated by the estates of two deceased individuals denied health coverage by UnitedHealth. It seeks class-action status, potentially representing tens of thousands nationwide. 

Demonstrating these claims, an investigation by Stat News delves into internal documents, communications, and testimonies from former NaviHealth employees, unraveling the controversial practices surrounding nH Predict.

Amber Lynch, an occupational therapist, and former NaviHealth case manager, expressed disillusionment during her tenure, emphasizing the company’s shift from patient advocacy to profit-driven motives. 

Lynch’s account underscores the dehumanizing impact of prioritizing monetary gains over patient dignity.

Functionality and Criticisms of nH Predict:

AI-based Denials

UnitedHealth reportedly implemented nH Predict in November 2019, employing it to estimate post-acute care needs for Medicare Advantage Plan patients. The algorithm, drawing from a database of 6 million medical cases, calculates medical requirements, length of stay, and discharge dates. 

However, criticisms arise as the algorithm allegedly overlooks crucial factors such as associated disorders, hindering accurate predictions.

Draconian Estimates and Denied Information

The lawsuit contends that nH Predict’s estimates often lead to draconian outcomes, with patients receiving payment denials after exceptionally short stays in nursing homes. 

Furthermore, allegations suggest that UnitedHealth denies requests from patients and doctors to access nH Predict’s reports, citing proprietary information.

Shifting Priorities at NaviHealth

The investigation reveals a significant shift in NaviHealth’s focus following its acquisition by UnitedHealth in 2020. The emphasis reportedly moved from patient advocacy to stringent performance metrics, prompting concerns about the algorithm’s accuracy and its impact on patient care.

Defending the Algorithm and Alleged Targeted Requirements:

UnitedHealth’s subsidiary, Optum Health, denies that nH Predict determines coverage decisions, portraying it as a guide for informing caregivers about a patient’s needs. The company asserts that coverage determinations adhere to CMS coverage criteria and the member’s plan terms, dismissing the lawsuit as lacking merit.

Contrary to Optum Health’s stance, documents obtained by Stat reveal that NaviHealth case managers face stringent requirements tied to nH Predict’s projections. Managers failing to align patient stay within specified percentages face disciplinary actions or termination.

Case managers undergo specific training to defend nH Predict’s estimates to patients and caregivers. The training includes tactics for countering objections, emphasizing the algorithm’s severity-adjusted comparisons to similar patients nationwide.

Unveiling Patient Plights

Patients who successfully appeal AI-backed denials face short-lived victories, as UnitedHealth reportedly issues new denials shortly after. A former case manager reveals a pattern of restarting case reviews post-appeal, resulting in recurring denials.

Two families, the Lokkens and Tetzloffs, share harrowing experiences of denied coverage, appealing multiple times and enduring significant out-of-pocket expenses for essential care. 

The lawsuit, alleging breach of contract and insurance law violations, seeks redress for actual damages, emotional distress, and an end to AI-based claims denials.

Conclusion:

The unfolding legal battle against UnitedHealth and its nH Predict algorithm brings to light a concerning narrative of denied healthcare coverage, questionable AI practices, and the potential prioritization of financial interests over patient well-being. The case emphasizes the necessity of using AI in the healthcare sector in a moral and open manner as it develops.

You may also see: Mandating AI Regulation: Sundar Pichai’s Striking Climate Challenges

FAQs:

Q1: How does nH Predict estimate post-acute care needs?

nH Predict utilizes a database of 6 million medical cases to estimate post-acute care needs by considering factors such as age, living situation, and physical functions.

Q2: What allegations does the lawsuit make against UnitedHealth and NaviHealth?

The lawsuit alleges breach of contract, breach of good faith and fair dealing, unjust enrichment, and insurance law violations by UnitedHealth and NaviHealth, specifically regarding the use of the nH Predict algorithm.

Q3: How does UnitedHealth respond to the accusations, and what is their defense strategy?

UnitedHealth’s subsidiary, Optum Health, denies that nH Predict determines coverage decisions and asserts that the lawsuit lacks merit. They emphasize adherence to CMS coverage criteria and plan terms in making coverage determinations.

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Aliha Zulfiqar
Aliha Zulfiqarhttp://thetricenet.com
With a major in English Language and Literature, I'm a dedicated SEO Content Writer. Also, I love to write about technology. With over 2 years of experience, I've had the privilege of contributing to various renowned platforms. As I look forward to the future, I am committed to refining my work and delivering content that stands out.

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