A newly filed lawsuit alleges that Humana used artificial intelligence algorithms to deny key rehabilitation care for seniors.
The suit echoes similar allegations against UnitedHealthcare, and the two are the largest players in the Medicare Advantage market. The plaintiffs say that the insurer relied on naviHealth’s nH Predict tool to make coverage determinations in long-term care.
The company, which is now a subsidiary of UnitedHealth Group’s Optum, has also been at the center of lawsuits against UHC. The nH Predict algorithm projects how long a patient will need rehabilitative services based on “rigid and unrealistic predictions for recovery,” according to the lawsuit.
“As such, Humana makes coverage determinations not based on individual patients’ needs, but based on the outputs of the nH Predict AI Model, resulting in the inappropriate denial of necessary care prescribed by the patients’ doctors,” the plaintiffs said in the suit. “Humana’s implementation of the nH Predict AI Model resulted in a significant increase in the number of post-acute care coverage denials.”
A Humana spokesperson said the insurer does not comment on pending litigation.
In addition to questioning the algorithm’s methodology itself, the lawsuit alleges that employees were pressured to keep up with the model’s targets, facing discipline or termination if they did not do so.
The lawsuit was brought by two individual plaintiffs, but they say the affected class could “number in the thousands to millions.”
One of the plaintiffs, 86-year-old JoAnne Barrows, was discharged to a rehabilitation facility in November 2021 after being hospitalized following a fall. She was under a non-weight-bearing order for six weeks due to a leg injury, according to the lawsuit.
Humana informed Barrows that she would cancel her coverage after just two weeks in the rehabilitation facility, according to the lawsuit, though she was to be non-weight-bearing for an additional month. She appealed the decision but was denied, forcing her family to pay out-of-pocket for the rehab she needed, according to the suit.
A newly filed lawsuit alleges that Humana used artificial intelligence algorithms to deny key rehabilitation care for seniors.
The suit echoes similar allegations against UnitedHealthcare, and the two are the largest players in the Medicare Advantage market. The plaintiffs say that the insurer relied on naviHealth’s nH Predict tool to make coverage determinations in long-term care.
The company, which is now a subsidiary of UnitedHealth Group’s Optum, has also been at the center of lawsuits against UHC. The nH Predict algorithm projects how long a patient will need rehabilitative services based on “rigid and unrealistic predictions for recovery,” according to the lawsuit.
“As such, Humana makes coverage determinations not based on individual patients’ needs, but based on the outputs of the nH Predict AI Model, resulting in the inappropriate denial of necessary care prescribed by the patients’ doctors,” the plaintiffs said in the suit. “Humana’s implementation of the nH Predict AI Model resulted in a significant increase in the number of post-acute care coverage denials.”
A Humana spokesperson said the insurer does not comment on pending litigation.
In addition to questioning the algorithm’s methodology itself, the lawsuit alleges that employees were pressured to keep up with the model’s targets, facing discipline or termination if they did not do so.
The lawsuit was brought by two individual plaintiffs, but they say the affected class could “number in the thousands to millions.”
One of the plaintiffs, 86-year-old JoAnne Barrows, was discharged to a rehabilitation facility in November 2021 after being hospitalized following a fall. She was under a non-weight-bearing order for six weeks due to a leg injury, according to the lawsuit.
Humana informed Barrows that she would cancel her coverage after just two weeks in the rehabilitation facility, according to the lawsuit, though she was to be non-weight-bearing for an additional month. She appealed the decision but was denied, forcing her family to pay out-of-pocket for the rehab she needed, according to the suit.