A Glimpse of Institutional AI: Patients Sue Over AI Denied Claims
January 31, 2024
This essay is the work of a dumb dinobaby. No smart software required.
AI algorithms are revolutionizing business practices, including whether insurance companies deny or accept medical coverage. Insurance companies are using more on AI algorithms to fast track paperwork. They are, however, over relying on AI to make decisions and it is making huge mistakes by denying coverage. Patients are fed up with their medical treatments being denied and CBS Moneywatch reports that a slew of “Lawsuits Take Aim At Use Of AI Tool By Health Insurance Companies To Process Claims.”
The defendants in the AI insurance lawsuits are Humana and United Healthcare. These companies are using the AI model nHPredict to process insurance claims. On December 12, 2023, a class action lawsuit was filed against Humana, claiming nHPredict denied medically necessary care for elderly and disabled patients under Medicare Advantage. A second lawsuit was filed in November 2023 against United Healthcare. United Healthcare also used nHPredict to process claims. The lawsuit claims the insurance company purposely used the AI knowing it was faulty and about 90% of its denials were overridden.
The AI model is supposed to work:
“NHPredicts is a computer program created by NaviHealth, a subsidiary of United Healthcare, that develops personalized care recommendations for ill or injured patients, based on “real world experience, data and analytics,’ according to its website, which notes that the tool “is not used to deny care or to make coverage determinations.’
But recent litigation is challenging that last claim, alleging that the “nH Predict AI Model determines Medicare Advantage patients’ coverage criteria in post-acute care settings with rigid and unrealistic predictions for recovery.” Both United Healthcare and Humana are being accused of instituting policies to ensure that coverage determinations are made based on output from nHPredicts’ algorithmic decision-making.”
Insurance companies deny coverage whenever they can. Now a patient can talk to an AI customer support system about an AI system’s denying a claim. Will the caller be faced with a voice answering call loop on steroids? Answer: Oh, yeah. We haven’t seen or experienced what’s coming down the cost-cutting information highway. The blip on the horizon is interesting, isn’t it?
Whitney Grace, January 31, 2024
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