Health insurance giants: AI tool in lawsuits’ crosshairs for claims

Key Elements:

  • Health insurance giants United Healthcare and Humana are facing legal action over the use of an artificial intelligence tool to process claims. These lawsuits allege wrongful denial of coverage for necessary medical services.
  • The increase in use of AI technology in the health insurance sector is raising fears of higher claims denials, potentially impacting the quality of medical care for chronically ill and elderly patients.
  • The AI model in question, nHPredict, is also accused of making coverage decisions based on overly stringent and unrealistic recovery predictions.

The escalating application of AI in the health insurance industry is encountering mounting legal obstacles. Patients are alleging these companies are abusing this technology to wrongfully deny medical services coverage. Both United Healthcare and Humana face criticism for their use of an AI model named nHPredict, with claimants arguing its use results in unjustifiably high coverage claim denials. This is driving calls for increased government oversight of this currently mostly unregulated AI application.

One class action, begun on September 12, alleges Humana used nHPredict to unrightfully deny essential care for elderly and disabled patients with coverage under Medicare Advantage. Another accuses United Healthcare of using the same model to reject claims, despite apparent knowledge that about 90% of its denials were erroneous.

Both United Healthcare and Humana reportedly have policies insisting that coverage decisions derive from nHPredict’s algorithmic decision-making outputs. The AI model is said to determine Medicare Advantage patients’ post-acute care settings coverage with “rigid and unrealistic recovery predictions.”

David Lipschutz, a lawyer advocating for Medicare patients, noted an increase in “more frequent” and “inappropriate” insurance claim denials coinciding with AI’s growing use in determining Medicare patient coverage. Nearly one in five insurance claims was rejected in 2021, a rise from a few years previously. However, without insurers needing to disclose their coverage decision reasoning, it’s challenging to definitively attribute this surge in denials to AI tool use.

The lawsuits against UnitedHealthcare and Humana could drive regulation of AI technology in the health insurance industry, even if their resolution may take years. As these cases, potential legislation, and wider perceptions challenge these practices, it is hoped that such objectionable behaviors will decrease.

In conclusion, the growing use of AI in the health insurance sector has raised several concerns, particularly around the increased rejection of claims, which could harm the healthcare access of elderly and chronically ill patients. Though technology offers significant advantages, regulation and oversight are necessary to prevent misuse and ensure patient care isn’t compromised.