On April 22, 2024, Plaintiffs who had filed a lawsuit against Humana, Inc. (Humana) alleging denial of post-acute care coverage by the “illegal and undisclosed deployment of artificial intelligence (AI) in place of real doctors” under Medicare Advantage plans, filed an Amended Complaint in the U.S. District Court for the Western District of Kentucky.
This case bears many similarities to the one brought against UnitedHealth Group, Inc., and its subsidiaries UnitedHealthCare, Inc., and naviHealth, Inc. (naviHealth). In fact, Humana is said to have ‘collaborated’ with naviHealth and utilized the same nH Predict AI Model developed by that entity.
REASONS FOR AI-BASED DENIALS OF COVERAGE UNDER THE AMENDED COMPLAINT
Humana is said to have used the nH Predict AI Model to make coverage decisions for post-acute care patients in a way that maximizes the likelihood of inappropriate denial of necessary care, resulting in a “clear financial windfall in the form of policy premiums without having to pay for promised care.”
According to paragraph 4 of the Amended Complaint, rather than Humana, it is the elderly Plaintiffs themselves who end up bearing the costs for post-acute care as they are “forced to deplete family savings to continue receiving necessary medical care,” because they are prematurely “kicked out of care facilities nationwide.”
According to the Amended Complaint, financial incentives for Humana also include “eliminating the labor costs associated with paying doctors and other medical professionals for the time needed to conduct an individualized, manual review of each of its insured’s claims.”
HOW THE AI MODEL IS DEPLOYED
The nH AI Model attempts to “predict the amount of post-acute care a patient “should” require, pinpointing the precise moment when Humana will cut off payment for a patient’s treatment.”
Such predictions are said to be made by the model by comparing the following 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”:
- A patients’ diagnosis;
- A patients’ age;
- A patients’ living situation; and
- Physical function to similar patients.
The model is also said to “spit out generic recommendations based on incomplete and inadequate medical records and fails to adjust to a patient’s individual circumstances.”
Humana is said to prioritize the nH AI Model over human employees, overriding “real doctor’s determinations” and limiting employees’ discretion to deviate from the model’s predictions.
HOW THE USE OF THE AI MODEL IS SAID TO VIOLATE THE CITED LAWS
A common set of actions – the improper use of the nH AI Model to the exclusion of human employees – is said to provide the basis for violations of eight causes of action that include breach of contract, insurance bad faith, and common law fraud.
They involve the following allegations:
- Humana fraudulently misled its insureds into believing their health plans would individually assess their claims and pay for necessary care;
- The written terms explaining plan coverage state that Humana is obligated to provide benefits for covered health services and must pay all reasonable and medically necessary expenses incurred by a covered member;
- The Plaintiffs and Class members had their post-acute care coverage determined by the nH Predict AI Model resulting in Humana failing to use reasonable standards in evaluating the individual claims;
- By engaging in this misconduct, Humana breached its fiduciary duties, including the duties of good faith and fair dealing, because its conduct serves Humana’s own economic self-interest and elevates Humana’s interests above the interests of the insureds; and,
- Use of the nH AI Model to deny claims undermines principles of fairness and meaningful claim evaluation.
Humana’s response to the Amended Complaint is currently expected in early June.
Categories: AI
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