On May 20, 2024, UnitedHealth Group, Inc. (UHG), and its Co-Defendant subsidiaries filed a motion to dismiss the Plaintiffs’ Amended Complaint in the federal case alleging denial of post-acute care under Medicare Advantage due to decisions made by an AI model.
BACKGROUND
Brought in the United States District Court for the District of Minnesota, the Plaintiffs were beneficiaries of Medicare Advantage plans under which the Defendants were said to have used their nH Predict artificial intelligence model to make coverage determinations based on “generalized data from the nH Predict system, not on the facts specific to Plaintiff’s and Class member’s claims.”
According to the Amended Complaint, this was part of an effort to systematically deny the claims of the Plaintiffs and avoid paying for promised care and thus improperly profit at the expense of elderly patients.
The claims of the Plaintiffs and allegations surrounding the use of the AI model have been covered by the Digital Health Law Group more fully in a previous article about their Amended Complaint.
USE OF AI MODELS NOT ADDRESSED IN-DEPTH DUE TO PROCEDURAL ARGUMENTS
The Defendants argue that since each of the claims against them involve “at bottom, a coverage determination concerning Medicare benefits,” the Plaintiffs’ claims are preempted by the Medicare Act and should be dismissed.
More specifically, the Defendants say that each claim is “based on the allegation that Defendants improperly reviewed Plaintiffs preauthorization requests or claims for benefits leading to a denial of coverage for their post-acute care.” Asserting that Plaintiffs have not yet exhausted their administrative remedies for such claims under the Medicare Act, they argue that the Federal Court does not have jurisdiction.
Because they argue that procedurally, preemption by the Medicare Act calls for the dismissal of the Plaintiffs claims, UHG and its Co-Defendants don’t address factual issues surrounding the alleged use of the nH Predict AI model in coverage determinations. The Defendants make various additional procedural arguments as to why the Plaintiffs’ claims should be dismissed.
How the Plaintiffs’ claims relate to artificial intelligence can be seen in an April 29, 2024, article from the Digital Health Law Group.
STANDARDS & REGULATIONS PERTAINING TO THE USE OF AI IN COVERAGE DETERMINATIONS
Although they don’t get into factual issues surrounding the use of their nH Predict AI model, the Defendants do set forth what they believe to be the applicable standard when it comes to the use of AI in Medicare coverage determinations.
This is related to their position that the Medicare Act applies to the Plaintiff’s claims, and they state that CMS regulations under the Act specify “who must make coverage determinations.” They further state that according to CMS, an “algorithm or software tool may be used to assist MA plans in making coverage determinations, but it is the responsibility of the MA organization to ensure that the algorithm or artificial intelligence complies with all applicable rules for how coverage determinations by MA organizations are made.”
According to an Order filed on the Court’s Docket, the Plaintiffs have until on or before June 24, 2024, to file a responsive memorandum.
Categories: AI
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