UnitedHealthcare, the largest health insurance company in the US, faces a lawsuit filed in the US District Court for the District of Minnesota. The lawsuit claims that the company is using an AI algorithm called nH Predict to override doctors’ judgments, resulting in the wrongful denial of critical health coverage for elderly patients. This alleged practice has led to patients being prematurely discharged from rehabilitation programs and care facilities, compelling them to use their savings for necessary care that should be covered by their government-funded Medicare Advantage Plan.

The lawsuit, brought by the estates of two deceased individuals whom UnitedHealth denied health coverage, seeks class-action status for potentially thousands of similarly affected individuals across the country. An investigation by Stat News supports the claims made in the lawsuit, based on internal documents, communications, and interviews with former employees of NaviHealth, the UnitedHealth subsidiary that developed nH Predict.

The AI algorithm, nH Predict, estimates post-acute care needs for patients on Medicare Advantage Plans by analyzing data from a database of medical cases from 6 million patients. However, the algorithm has come under scrutiny for not considering various relevant factors in patients’ health and recovery time, potentially leading to overly restrictive estimates.

Patients and their doctors who have requested access to nH Predict’s reports have been denied, with UnitedHealth citing proprietary information. Furthermore, physicians’ judgments regarding post-acute care have been overridden based on the algorithm’s predictions.

The lawsuit argues that UnitedHealth should have been aware of the algorithm’s inaccuracies, given the high rate of reversals when patients appeal denials based on nH Predict estimates. Despite these concerns, NaviHealth employees have been directed to adhere closely to the algorithm’s predictions, facing disciplinary actions if they deviate.

UnitedHealth contends that nH Predict is used as a guide to inform providers, families, and caregivers about patients’ care needs. However, the lawsuit raises questions about the algorithm’s accuracy and the financial implications for UnitedHealth. The lawsuit accuses UnitedHealth and NaviHealth of multiple violations and seeks damages, restitution, and an end to AI-based claims denials.

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