UnitedHealthcare accused of using AI that denies critical medical care coverage

[midian182]

A hot potato: In yet another story about the damaging effects of faulty artificial intelligence, the largest health insurance company in the US, UnitedHealthcare, is being sued over claims it is using a flawed AI model. The system is said to have wrongfully denied health coverage to critical elderly patients and disagreed with doctors' determinations.

The lawsuit filed in the US District Court for the District of Minnesota comes from the estates of two now-deceased men who needed long-term care in post-acute facilities. The families of these men were forced to pay a combined $210,000 out of pocket for their therapy and care before their deaths.

The suit alleges that UnitedHealth repeatedly and wrongfully refused to pay the healthcare claims of the two seniors, who were using the Medicare Advantage Plans. It adds that such incidents have been going on since at least 2020, when UnitedHealthcare acquired post-acute care management firm Navihealth.

The lawsuit followed an investigation by Stat News about the use of an AI algorithm called nH Predict developed by Navihealth. The algorithm is used to anticipate how long patients will stay in rehab following acute injuries, illness, or events. Post-acute care includes the likes of nursing homes and rehab centers. The algorithm reportedly does this by examining a database of medical cases from 6 million patients and estimating a patients' medical requirements and length of stay.

The lawsuit alleges that the AI system has a 90% error rate and overruled the post-acute care opinions of physicians. Furthermore, claims that nH Predict failed to take into account individual patient needs, such as comorbidities (having multiple conditions or diseases) and contracting an illness while staying at a facility.

Another damning section of the suit claims that while only a few patients appealed coverage denials that were based on nH Predict estimates, over 90% of them were reversed through internal appeals processes or federal Administrative Law Judge proceedings.

"Under Medicare Advantage Plans, patients who have a three-day hospital stay are typically entitled to up to 100 days in a nursing home," the lawsuit states, citing Stat's investigation. "With the use of the nH Predict AI Model, [UnitedHealthcare] cut off payment in a fraction of that time. Patients rarely stay in a nursing home more than 14 days before they start receiving payment denials."

Former NaviHealth employees told Stat that once UnitedHealth took over, the focus moved from helping patients to making money and keeping post-acute care times as short as possible.

The UnitedHealth executive overseeing NaviHealth, Patrick Conway, was quoted in a company podcast saying: "If [people] go to a nursing home, how do we get them out as soon as possible?"

nH Predict is still being used today. UnitedHealth's subsidiary Optum Health told Ars Technica: "The NaviHealth predict tool is not used to make coverage determinations. The tool is used as a guide to help us inform providers, families, and other caregivers about what sort of assistance and care the patient may need both in the facility and after returning home. Coverage decisions are based on CMS coverage criteria and the terms of the member's plan. This lawsuit has no merit, and we will defend ourselves vigorously."

Permalink to story.

https://www.techspot.com/news/100895-unitedhealthcare-legal-battle-over-ai-denials-critical-medical.html

 

[havok585]

Imagine putting your life in the hands of an algorithm.

 

[madboyv1]

Wow that is just awful. It is already hard enough that physicians doctors have to fight against a company's predatory for-profit model of healthcare but an algorithm too? This reeks of the same level of incompetence and lack of due diligence as lawyers using ChatGPT without checking it's work, except people's lives are at stake.

Another damning section of the suit claims that while only a few patients appealed coverage denials that were based on nH Predict estimates, over 90% of them were reversed through internal appeals processes or federal Administrative Law Judge proceedings.

You would think that would be enough for any reasonable person/company to pull a product or service from circulation if the process had that high of an error rate and reversal rate, but no no... there is blood in the water money to be had/not spent.

 

[AlexIL]

That what happens once we put profitability/effectiveness before morality/humanity.

 

[yRaz]

I'm so happy that I don't have to go through some national provider like this. My employer has fantastic insurance and if I go out of network, it can cost me, but I've never been stuck with anything bigger than a $1500 medical bill when out of network. Considering I travel all over the US for work and have a epilepsy, I've had to have "critical care" a number of times out of network over the years. But my maximum out of network care costs for a "period"(my healthcare goes in 2, 6 month cycles instead of 1 year) is $1500 and my maximum in network costs are $375 a period.

I remember in my last job that my maximum out of pocket expenses were $15,000/yr and I had to have every doctors appointment approved. The US healthcare system is ****ed. As someone with a life-threatening medical condition I consider my insurance as part of my income because of how F***ed my insurance was from previous jobs. There have been years where I spent more on healthcare than I did on rent and utilities combined. The amount of money I've spent on medical expenses totals the down payment on a very nice house. I'm going to stop writing before I get too fired up.

 

[CrisisDog]

Ten years ago my daughter was in the hospital with RSV for a month. Other than an ambulance bill, we had to pay nothing. I was in the hospital for a week with COVID recently and had to pay $4000. The times have changed, it’s all about profit now. Saving a life is secondary, if that…

 

[axiomatic13]

Healthcare is a cost center, not a profit center. Not everything needs Capitalism applied.

 

[brucek]

The "AI" angle is irrelevant. I don't care whether it's bad AI, a bad spreadsheet, or a bad human - the bottom line is there is a dispute over honoring the terms of a contract, and if UH has not met its obligations it should be held accountable accordingly. Personally I suspect the "AI" is the least of the problems.

 

[RudyBob]

Would the result have been different if people had been making the determinations?

If you want affordable health care get the government out and get insurance companies out.

The cost of people that work in healthcare, the supplies to provide healthcare, etc are astronomical.

I don't like this it stinks

 

[MyIOnU]

Well we have couple doctors saying that starting next year they won't accept United Healthcare insurance anymore.

 

[Kam7r]

That what happens once we put profitability/effectiveness before morality/humanity.

Welcome to the US of A...

 

[Theinsanegamer]

Healthcare is a cost center, not a profit center. Not everything needs Capitalism applied.

Problem is some needs to pay for it. Everyone says the current system sucks, because it does, but the government run systems that function in the real world have their own buffet of major issues that nobody wants to address. Like wait times. Or access to newer, more expensive medications. Or access to specialists. Especially post covid, the flaws of government funded systems have become well apparent.

It's easy to say "capitalism has no place in healthcare" when you're not the one being told that your major issue, since it is not immediately life threatening, will have a 2 year wait time, and you have to suck it up and deal with it. Or when you're being told you have a disease like cancer, and there is this new drug to treat it, but it costs too much so you get the less effective, harsher drug. Or you're canadian and ask for a wheelchair ramp to be installed since you lost your legs serving in the military, and are told to go get MAID (which is euthanasia for those not in the know) because you cost the government too much (and yes, this DID happen in canada).

The only system that really seems to work is the Japanese system. But, that only works in large part because the population isnt obese. It would never work in the states or in europe, where taking care of your body is seen like a homework assignment to skip instead of a crucially important task.

 

[PEnnn]

Strange how most European countries have a very good handle on healthcare, but the US's answer is a bunch of greedy companies!

The US healthcare system is just another business licensed to fleece its customers - whose lives depend on the mercy of such ghouls.

And before some clueless person points out that it doesn't work perfectly over there: I have lived there for over 15 years and it beats the carp of anything the US has to offer.

Unlike the US, over there neither a person or AI has a say if you got to live or not.

 

[sdms96825]

Why does the U.S. retirement group AARP continue to support UnitedHealthCare? I wonder how much AARP is getting paid to do so?

 

[VaRmeNsI]

Healthcare is a cost center, not a profit center. Not everything needs Capitalism applied.

Socialism ruins where capitalism isn't applied.

 

[Uncle Al]

Another good example why these sorts of companies MUST be tightly controlled by the Government and the eleminatioin of companies overruleing doctors decisions.....

 

[PEnnn]

Socialism ruins where capitalism isn't applied.

You haven't read the article, thoroughly.

In this case (and many others), capitalism has fatal (literally!!) results.

 

[kira setsu]

Strange how most European countries have a very good handle on healthcare, but the US's answer is a bunch of greedy companies!

The US healthcare system is just another business licensed to fleece its customers - whose lives depend on the mercy of such ghouls.

And before some clueless person points out that it doesn't work perfectly over there: I have lived there for over 15 years and it beats the carp of anything the US has to offer.

Unlike the US, over there neither a person or AI has a say if you got to live or not.

Hey!

Our answer to everything is greedy companies fleecing the public, not just healthcare.

just clarifying it.

 

[RudyBob]

That what happens once we put profitability/effectiveness before morality/humanity.

Your tenant is wrong. Morality has nothing to do with profits. Morality is far down everyone's list. What is at the top is self and when someone goes to Wal-Mart they want service. When someone needs healthcare they want no mistakes. The redundancy to help insure that, is in place and there has to be money there. Don't equate profitability/effectiveness with morality/humanity (which is something only individuals can be no matter what the corporate creed states.)

 

[VaRmeNsI]

You haven't read the article, thoroughly.

In this case (and many others), capitalism has fatal (literally!!) results.

Government prevents competition which leads to higher prices and death

 

[Random Commenter]

The "AI" angle is irrelevant. I don't care whether it's bad AI, a bad spreadsheet, or a bad human - the bottom line is there is a dispute over honoring the terms of a contract, and if UH has not met its obligations it should be held accountable accordingly. Personally I suspect the "AI" is the least of the problems.

It is certainly artificial but it's nowhere near intelligent, nor does it have any compassion. AI is just a buzzword for a clever algorithm and too many people fall for the schtick.

 

[axiomatic13]

Socialism ruins where capitalism isn't applied.

Will you listen to Truman?

 

[wiyosaya]

I'm so happy that I don't have to go through some national provider like this. My employer has fantastic insurance and if I go out of network, it can cost me, but I've never been stuck with anything bigger than a $1500 medical bill when out of network. Considering I travel all over the US for work and have a epilepsy, I've had to have "critical care" a number of times out of network over the years. But my maximum out of network care costs for a "period"(my healthcare goes in 2, 6 month cycles instead of 1 year) is $1500 and my maximum in network costs are $375 a period.

I remember in my last job that my maximum out of pocket expenses were $15,000/yr and I had to have every doctors appointment approved. The US healthcare system is ****ed. As someone with a life-threatening medical condition I consider my insurance as part of my income because of how F***ed my insurance was from previous jobs. There have been years where I spent more on healthcare than I did on rent and utilities combined. The amount of money I've spent on medical expenses totals the down payment on a very nice house. I'm going to stop writing before I get too fired up.

The provider does not seem to be the problem in this case. It seems to be the AI algorithm the provider is using.

 

[yRaz]

The provider does not seem to be the problem in this case. It seems to be the AI algorithm the provider is using.

The AI algorithm is only a mask. It is something that gives the company plausible deniability in legal cases. Insurance companies try to find ways to wiggle out of paying for anything all the time and this is just another one of their tactics. Now they're going to do a cost/benefit analysis to see if the fine they have to pay for using AI is less than what they would have had to pay out to policy holders. If it is then you better believe that insurance companies are going to start using AI a lot to manage certain types of approvals. The best part about denying people critical care for their health insurance is that dead people can't sue you.

 

[Theinsanegamer]

Strange how most European countries have a very good handle on healthcare, but the US's answer is a bunch of greedy companies!

The US healthcare system is just another business licensed to fleece its customers - whose lives depend on the mercy of such ghouls.

And before some clueless person points out that it doesn't work perfectly over there: I have lived there for over 15 years and it beats the carp of anything the US has to offer.

Unlike the US, over there neither a person or AI has a say if you got to live or not.

That European healthcare relies on said countries outsourcing their defense spending to the United States. They also rely on medications developed by those evil capitalist healthcare companies. Let's not get into the INSANE wait times in Europe VS America, the chronic care shortages, or the fact that, yes, you will get care, but that doesnt mean you will get GOOD care. You are stuck with whatever slop the government deems good enough for you.

And you still pay for it. EU taxes are NUTS compared to the US. That healthcare isnt free. Never has been.

You haven't read the article, thoroughly.

In this case (and many others), capitalism has fatal (literally!!) results.

Long wait times in "socialist" systems also have LITERALLY fatal results. But things like wait times and poor care always escape the comparison, it always comes down to money. One can look no further then the VA, and their claims that heart attacks are not immediate threats to life, to see how poorly a purely government run system would fair.