Patients with Humana’s Medicare Advantage plan have recently filed a class action suit in federal court for the Western District of Kentucky alleging that Humana “systematically denies” medically necessary rehabilitation care based on an algorithm using artificial intelligence. The lawsuit alleges that Humana used naviHealth’s nh Predict platform to make coverage determinations for long-term rehabilitation care without regard to patients’ individual medical needs. One of the named plaintiffs alleges that Humana denied rehabilitation care after two weeks based on the naviHealth platform even though her physician had issued a non-weight-bearing order for six weeks. The complaint alleges that nh Predict is highly inaccurate and that its use by Humana constitutes a “fraudulent scheme” that results in a “financial windfall” to Humana.
A similar lawsuit was brought by the estates of two deceased UnitedHealthcare Medicare Advantage members in federal district court for the District of Minnesota. This lawsuit alleges that United has illegally deployed artificial intelligence “in place of real medical professionals to wrongfully deny” medically necessary long-term care based on the naviHealth platform. The complaint alleges that the platform has a 90% error rate. As in the lawsuit against Humana, the complaint alleges that United’s use of the platform constitutes a “fraudulent scheme” that results in a “financial windfall” to United.
naviHealth is a subsidiary of UnitedHealth Group’s Optum.
Whatley Kallas’s provider clients have also found that health plans, including Medicare Advantage plans, regularly deny medically necessary care based on commercial software tools that do not take patients’ individual needs or physicians’ medical judgment into consideration.
The complaint against Humana, Barrows et al. v. Humana, Inc. is linked here. The complaint against United, Lokken et al. v. UnitedHealth Group, et al., is linked here.
The attorneys at Whatley Kallas, LLP will continue to follow these lawsuits as they proceed.