News: UHC sued for unethical use of AI in skilled nursing facility denials

CDI Strategies - Volume 17, Issue 53

UnitedHealthcare (UHC) is facing a class action lawsuit, alleging the company illegally used artificial intelligence (AI) to “systematically deny” skilled nursing facility (SNF) claims, according to Medscape.

The plaintiffs in the lawsuit are being represented by Clarkson Law, which claims that UHCs AI tool (nH Predict) has been used to avoid Medicare’s coverage determination standards.

According to Medscape, the nH Predict model utilizes a database of six million patients, allowing it to “estimate the ideal length of stay and target discharge date” for a given SNF patient. However, the results of these “estimations” are, according to Clarkson, less than accurate, with the nH Predict model yielding an error rate of approximately 90%.

For instance, the complaint cites a 91-year-old man who—after fracturing his leg and ankle—was denied physical therapy and, as a result, was forced to remain at his admitting hospital, leaving him with approximately $150,000 in out-of-pocket expenses.

"Every patient is entitled to a nuanced evaluation of their health care needs," said Zarrina Ozari, senior associate at Clarkson Law Firm, in a statement quoted by Medscape. "By replacing licensed practitioners with unchecked AI, UHC is telling its patients that they are completely interchangeable with one another and undervaluing the expertise of the physicians devoted to key elements of care."

According to an April 12, 2023, federal ruling, any medical necessity denial must be “reviewed by a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the service at issue."

The Minnesota district court is currently assessing whether the case ought to become a federal class action suit, which would allow any United States resident who has purchased a UHC Medicare Advantage plan in the past four years to join in the legal action against UHC.

Editor’s note: To read the Medscape article, click here. To read the 2023 federal ruling on medical necessity denials, click here.

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