Humana, one of the largest health insurance providers in the country, uses an artificial intelligence model that has an error rate of up to 90% to override doctors’ medical judgment and deny care to seniors on the company’s Medicare Advantage plans.
Lawsuit Against Humana
According to the lawsuit filed on Tuesday, Humana’s use of the AI model constitutes a “fraudulent scheme” that leaves elderly beneficiaries either with overwhelming medical debts or without the necessary care covered by their plans. In the meantime, the enormous insurance company is profiting financially.
Lawsuit Against Humana
The lawsuit was filed in federal court in West Virginia by two individuals who had Humana’s Medicare Advantage plan and stated that necessary and covered care had been wrongly denied, harming their health and finances. The lawsuit seeks to grant class action status for an unknown number of other beneficiaries across the country who may be in similar situations. Humana provides Medicare Advantage plans to 5.1 million people in the United States.
Use of the AI Model
In both cases, the plaintiffs claim that insurance companies use the flawed model to determine the precise cut-off date for payments blindly and illegally for post-incident care covered by Medicare plans, such as stays in skilled nursing facilities and inpatient rehabilitation centers. The AI-driven model determines these dates by comparing the patient’s diagnosis, age, living condition, and physical function against similar patients in a database of 6 million patients. In turn, the model provides an estimate of the patient’s medical needs, length of stay, and discharge date.
Challenges and Lawsuits
However, the plaintiffs allege that the model does not take into account the full circumstances of each patient, doctors’ recommendations, and the actual condition of the patient. They claim that the predictions are unjust and inflexible. For instance, under Medicare Advantage plans, patients who spend three days in the hospital are entitled to up to 100 days of covered care in nursing homes. But with the nH Predict model, patients rarely stay in nursing homes for more than 14 days before claims begin to be denied.
While a few individuals appeal coverage denials overall, more than 90 percent of those who appealed AI-based decision denials were successful in having the decision overturned. Nevertheless, insurance companies continue to use the model, and NavHealth employees are required to adhere to the AI forecasts, keeping the post-incident care duration within 1 percent of the days estimated by nH Predict. NavHealth employees who do not comply face penalties and termination. The lawsuit filed on Tuesday claims that Humana relies on the affected patients’ circumstances, lack of knowledge, and lack of resources to appeal wrong decisions backed by artificial intelligence.
Plaintiffs’ Cases
One of the plaintiffs in the lawsuit filed on Tuesday is Joanne Burrows from Minnesota. On November 23, 2021, Burrows, then 86 years old, was hospitalized after falling at home and breaking her leg. Doctors placed her leg in a cast and ordered her not to put any weight on it for six weeks. On November 26, she was transferred to a rehabilitation center for six weeks to recover. However, just two weeks later, coverage denials began from Humana. Burrows and her family filed appeals, but Humana denied the appeals, stating that Burrows was capable of returning home despite being bedridden and using a catheter.
Her family had no choice but to pay out of pocket. They tried to transfer her to a less expensive facility, but she received inadequate care there, and her health further deteriorated. Due to the poor quality of care, the family decided to take her home on December 22, even though she was still unable to use her injured leg and go to the bathroom by herself, and she continued to use a catheter.
The plaintiff
The other is Susan Haggood from North Carolina. On September 10, 2022, Haggood was hospitalized due to a urinary tract infection, sepsis, and spinal inflammation. She remained in the hospital until October 26 when she was transferred to a skilled nursing care facility. Upon transfer, she had eleven discharge diagnoses, including sepsis, acute kidney failure, kidney stones, nausea, vomiting, urinary tract infection, swelling in the spine, and an abscess in the spine. In the nursing facility, she was experiencing severe pain and was on the maximum allowable dose of pain medication, oxycodone. She also developed pneumonia.
On November 28, she returned to the hospital for an appointment, where her blood pressure spiked, and she was sent to the emergency room. There, doctors discovered that her condition had deteriorated significantly.
At the same time, on the previous day, November 27, Humana decided to deny coverage for part of her stay in the skilled nursing care facility, refusing to pay from November 14 to November 28. Humana stated that Haggood no longer required the level of care that the facility provided and that she should return home. The family paid $24,000 out of pocket for her care, and to date, Haggood remains in the skilled nursing care facility.
Litigation and Challenges
Overall, patients allege that Humana and United Health are aware that the nH Predict model is “extremely inaccurate” but use it anyway to avoid paying for covered care and to generate further profits. The denial of care is considered “systematic, unlawful, harmful, and oppressive.”
The lawsuit against Humana alleges breach of contract, unfair dealing, unjust enrichment, and bad faith insurance violations in multiple states. The lawsuit seeks damages for financial losses, emotional distress, the disgorgement of unjust profits, and/or the recovery of paid amounts, as well as to prevent Humana from using the AI-based model to deny claims.
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