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Another algorithm to say ‘no’ to your care

UnitedHealthcare is facing a lawsuit over an algorithm that denies Medicare Advantage beneficiaries care.

Nice try, UnitedHealthcare . . .

The nation’s largest health insurer has recently found itself in hot water over an algorithm it uses to deny rehabilitation care for Medicare Advantage beneficiaries.

According to a lawsuit filed in a Minnesota district court, UnitedHealthcare (United) and its subsidiary NaviHealth used an algorithm called nH Predict to deny medical claims from patients recovering from illnesses in nursing homes. United has been using nH Predict to deny claims since 2019.

What’s worse, the lawsuit alleges that United and NaviHealth knew the algorithm had a high error rate. In fact, the suit claims, more than 90 percent of patient claim denials from nH Predict were overturned following appeal.

The suit accuses United of breaking state law (in more than 20 jurisdictions, might we add) and breaching its contracts with members. Not only did the company allegedly break the law, but in doing so they may have contributed to unnecessary deaths: The suit comes after two United MA beneficiaries died after not receiving appropriate post-acute coverage following major medical events.

“The fraudulent scheme affords [UnitedHealth] 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 or forced to deplete family savings to continue receiving necessary medical care, all because an AI model ‘disagrees’ with their real live doctors’ determinations,” according to the suit.

United is not the first payor to use an algorithm to deny claims. Back in the spring, ProPublica reported Cigna’s use of an algorithm known as “PXDX” to automatically turn down medical claims, with the company’s doctors never having to open a single file.

It begs the question, then: What’s the point of patients going to see the doctor when their care will be denied automatically by an algorithm? Better yet, why even have doctors who spend years in medical school studying the human body and subsequent years in training learning how to treat it — when a computer system thinks it can do a better job with patient care?

And until more lawsuits call out payors’ bad behavior, insurers like United and Cigna will continue to get away with antics like these.

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