UnitedHealth’s artificial intelligence denies claims in error, lawsuit says

On Nov 21, 2023

For years, vital decisions about who got medical care coverage took place in back offices at health insurance companies. Now, some of those life-altering decisions are being made by artificial intelligence programs.

At least that’s the contention of the two families who sued UnitedHealth Group this week, saying the insurance giant used emerging technology to deny or shorten rehabilitation stays for two elderly men in the months before they died.

They say that UnitedHealth’s artificial intelligence, or AI, is making “rigid and unrealistic” determinations about what it takes for patients to recover from serious illnesses and denying them care in skilled nursing and rehab centers that should be covered under Medicare Advantage plans, according to a federal lawsuit filed in Minnesota by the estates of two elderly Wisconsin patients. The lawsuit, which seeks class-action status, says it is illegal to let AI override doctors’ recommendations for these men and patients like them. The families say assessments like that should be done by medical professionals.

The families note in the suit that they believe the insurance company is denying care to elderly patients who won’t fight back even though evidence shows the AI is doing a lackluster job of assessing people’s needs. The company used algorithms to determine coverage plans and override doctors’ recommendations despite the AI program’s astonishingly high error rate, they say.

More than 90% of patient claim denials were overturned through internal appeals or a federal administrative law judge, according to court documents. But in reality, few patients challenged the algorithms’ determinations. A tiny percentage of patients − .2% − choose to fight claim denials through the appeals process. The vast majority of people insured by UnitedHealth’s Medicare Advantage plans “will either pay out-of-pocket costs or forgo the remainder of their prescribed post-acute care,” the lawsuit says.

Attorneys representing the families suing the Minnesota-based insurance giant said the high rate of denials is part of the insurance company’s strategy.

“They’re placing their own profits over the people that they are contracted with and then legally bound to cover,” said Ryan Clarkson, a California attorney whose law firm has filed several cases against companies using AI. “It’s that simple. It’s just greed.”

UnitedHealth told USA TODAY in a statement naviHealth’s AI program, which is cited in the lawsuit, isn’t used to make coverage determinations.

“The tool is used as a guide to help us inform providers, families and other caregivers about what sort of assistance and care the patient may need both in the facility and after returning home,” the company said.

Coverage decisions are based on the Centers for Medicare & Medicaid Services’ criteria and the consumer’s insurance plan, the company said.

“This lawsuit has no merit, and we will defend…