On April 5, 2024, the enrollees in Medicare Advantage Plans that had filed a class action complaint against UnitedHealth Group, Inc., United Healthcare, Inc., and naviHealth, Inc., alleging denial of care due to coverage determinations made by artificial intelligence filed an Amended Complaint.
Brought in the United States District Court for the District of Minnesota, the case focuses on post-acute care settings where the Defendant health plans allegedly used an artificial intelligence model, nH Predict, to make determinations as to coverage based on “generalized data from the nH Predict system, not on the facts specific to Plaintiff’s and Class member’s claims.” As a result, the Amended Complaint says that Plaintiffs were denied needed health care services.
ALLEGED REASONS FOR DENIAL OF COVERAGE
According to the Amended Complaint, the Defendants chose to override the treating physician’s determinations as to medically necessary care through the use of the nH Predict model in order to systematically deny claims to avoid paying for promised care and improperly profit at the expense of elderly patients.
Such allegations are made more serious by the fact that Medicare Advantage plans, as noted in the Amended Complaint, are “a type of health plan offered by private companies that contract with Medicare” and use taxpayer dollars.
ABOUT THE nH PREDICT AI MODEL
The nH Predict AI model was developed by Defendant naviHealth, Inc., a wholly owned subsidiary of Defendant UnitedHealth Group, Inc. According to the Amended Complaint, the creator of the model “specifically intended for it to save insurance companies money in the post-acute setting, which had previously been a highly unprofitable aspect of Medicare Services.”
According to the Amended Complaint, the model has allegedly been deployed in a manner in which it “attempts to predict the amount of post-acute care a patient “should” require, pinpointing the precise moment when Defendants will cut off payment for a patient’s treatment.” It is said to do so by purporting to “compare a patient’s diagnosis, age, living situation, and physical function to similar patients in a database of six million patients it compiled over the years of working with providers to predict patient’s medical needs, estimated length of stay, and target discharge date.”
It is also said to apply a “rigid criteria,” and “unrealistic predictions” when it comes to approval of post-acute care claims and is said to be highly inaccurate with over 90 percent of patient claim denials being reversed through an internal appeal process or by a federal Administrative Law Judge, and over 80 percent of prior authorization request denials reversed on appeal.
PHYSICIAN DETERMINATIONS v. nH PREDICT AI MODEL
As seen above, Plaintiffs allege that the Defendants use of the nH Predict AI model was for the purpose of denying coverage and therefore, that Defendants were incentivized to have the model follow rigid criteria more likely to result in denials and provide unrealistic predictions. However, the Amended Complaint places a greater focus on the allegations that the Defendants delegated their responsibility to the models and left physicians and other human beings out of the process. As paragraph 39 states, “Defendants wrongfully delegate their obligation to evaluate and investigate claims to the nH Predict AI Model in breach of the insurance agreement.”
More specifically, the Amended Complaint states that “Defendants have deliberately created a process that systematically fails to have a doctor determine individual coverage for post-acute care in a thorough, fair, and objective manner, instead using the nH Predict model to supplant real doctor’s recommendations and patient’s medical needs.”
This allegedly allows for a process lacking in transparency, with the Plaintiffs alleging that “the outcome reports generated by nH Predict are rarely, if ever, communicated with patients or their doctors.”
The Plaintiffs go so far as to claim that the Defendants evaded the legally required process for reviewing patient claims by their delegation of care determinations to the nH Predict model and state that Plaintiffs were misled into believing that “health plans would individually assess their claims.”
CAUSES OF ACTION AND DAMAGES SOUGHT
Although the use of the nH Predict model is central to the allegations of the Plaintiffs, it should be noted that there are no causes of action in the Amended Complaint specific to artificial intelligence.
The Plaintiffs allege breach of contract in the form of the insurance agreements between the Plaintiffs and Defendants and related causes of action such as breach of the implied covenant of good faith and fair dealing and unjust enrichment by the Defendants. There are also causes of action for “insurance bad faith,” unfair and deceptive insurance practices, negligence per se and violations of California’s Unfair Competition law.
The Plaintiffs are seeking actual, consequential, statutory and punitive damages and awards for emotional distress and restitution. They are also seeking that the Defendants be enjoined from continuing the “improper and unlawful claim handling practices” found in the Amended Complaint.
According to an Order entered by the Court, the Defendant’s Answers to the Amended Complaint are currently due on or before May 20, 2024.
Categories: AI
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