On July 15, 2024, UnitedHealth Group (“UHG”) and its co-defendants filed a reply brief supporting their motion to dismiss a class action lawsuit alleging improper use of artificial intelligence to deny Medicare Advantage claims. Filed in the United States District Court for the District of Minnesota, the brief argues that the claims are preempted by the Medicare Act and that the plaintiffs failed to exhaust their administrative remedies.
According to the Complaint, the plaintiffs and class members enrolled with defendants to receive Medicare Advantage health insurance coverage but were wrongfully denied access to post-acute care due to UHG’s use of the nH Predict Model AI system. They allege that the 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 AI Model to supplant doctors’ recommendations.”
As to the nH Predict Model, according to the Complaint, it “purports 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 patients’ medical needs, estimated length of stay, and target discharge date.” It then “attempts to predict the amount of post-acute care a patient ‘should’ require.” However, the model is alleged to apply “rigid criteria from which Defendants’ employees are instructed not to deviate,” and is said to be wrongfully utilized.
UHG’s preemption arguments apply to both the plaintiffs’ state statutory claims and common law claims. In arguing that plaintiffs’ claims fail to exhaust administrative remedies, UHG says that they “arise under” the Medicare Act because they are “inextricably intertwined” with claims for Medicare benefits.
The brief also argues that plaintiffs have not met the jurisdictional, allegedly non-waivable, presentment requirement, stating “this is not the type of claim for which waiver applies.”
It also argues that plaintiffs should not be excused from the exhaustion requirement by filing the matter in Court rather than reaching a decision based on the administrative process, because, among other things, “Supreme Court precedent dictates that exhaustion may be excused under very narrow circumstances and only for cases with Constitutional questions.”
According to a Minute Entry filed on August 29, 2024, a hearing was held on UHG’s motion to dismiss on that day and that the “motion was argued and taken under advisement.” The Court further stated that the Order is to follow.
Categories: AI
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