Humana also using AI tool with 90% error rate to deny care, lawsuit claims
The AI model, nH Predict, is the focus of another lawsuit against UnitedHealth.
Humana, one the nation’s largest health insurance providers, is allegedly using an artificial intelligence model with a 90 percent error rate to override doctors’ medical judgment and wrongfully deny care to elderly people on the company’s Medicare Advantage plans.
According to a lawsuit filed Tuesday, Humana’s use of the AI model constitutes a “fraudulent scheme” that leaves elderly beneficiaries with either overwhelming medical debt or without needed care that is covered by their plans. Meanwhile, the insurance behemoth reaps a “financial windfall.”
The lawsuit, filed in the US District Court in western Kentucky, is led by two people who had a Humana Medicare Advantage Plan policy and said they were wrongfully denied needed and covered care, harming their health and finances. The suit seeks class-action status for an unknown number of other beneficiaries nationwide who may be in similar situations. Humana provides Medicare Advantage plans for 5.1 million people in the US.
It is the second lawsuit aimed at an insurer’s use of the AI tool nH Predict, which was developed by NaviHealth to forecast how long patients will need care after a medical injury, illness, or event. In November, the estates of two deceased individuals brought a suit against UnitedHealth—the largest health insurance company in the US—for also allegedly using nH Predict to wrongfully deny care.
Humana did not respond to Ars’ request for comment by the time this story initially published, but a spokesperson has since provided a statement, emphasizing that there is a “human in the loop” whenever AI tools are used. It continues:
Coverage decisions are made based on the health care needs of patients, medical judgment from doctors and clinicians, and guidelines put in place by CMS. It’s important to note that adverse coverage decisions are only made by physician medical directors.
United Health previously said that “the lawsuit has no merit, and we will defend ourselves vigorously.”
In both cases, the plaintiffs claim that the insurers use the flawed model to pinpoint the exact date to blindly and illegally cut off payments for post-acute care that is covered under Medicare plans—such as stays in skilled nursing facilities and inpatient rehabilitation centers. The AI-powered model comes up with those dates by comparing a patient’s diagnosis, age, living situation, and physical function to similar patients in a database of 6 million patients. In turn, the model spits out a prediction for the patient’s medical needs, length of stay, and discharge date.
But, the plaintiffs argue that the model fails to account for the entirety of each patient’s circumstances, their doctors’ recommendations, and the patient’s actual conditions. And they claim the predictions are draconian and inflexible. For example, under Medicare Advantage plans, patients who have a three-day hospital stay are typically entitled to up to 100 days of covered care in a nursing home. But with nH Predict in use, patients rarely stay in a nursing home for more than 14 days before claim denials begin.