UnitedHealthcare, the largest health insurance company in the US, is allegedly using a deeply flawed AI algorithm to override doctors’ judgments and wrongfully deny critical health coverage to elderly patients. This has resulted in patients being kicked out of rehabilitation programs and care facilities far too early, forcing them to drain their life savings to obtain needed care that should be covered under their government-funded Medicare Advantage Plan.

That’s all according to a lawsuit filed this week in the US District Court for the District of Minnesota. The lawsuit is brought by the estates of two deceased people who were denied health coverage by UnitedHealth. The suit also seeks class-action status for similarly situated people, of which there may be tens of thousands across the country.

The lawsuit lands alongside an investigation by Stat News that largely backs the lawsuit’s claims. The investigation’s findings stem from internal documents and communications the outlet obtained, as well as interviews with former employees of NaviHealth, the UnitedHealth subsidiary that developed the AI algorithm called nH Predict.

“By the end of my time at NaviHealth I realized: I’m not an advocate, I’m just a moneymaker for this company,” Amber Lynch, an occupational therapist and former NaviHealth case manager, told Stat. “It’s all about money and data points,” she added. ‘It takes the dignity out of the patient, and I hated that.”

AI-based denials

According to the lawsuit, UnitedHealth started using nH Predict in at least November 2019, and it is still in use. The algorithm estimates how much post-acute care a patient on a Medicare Advantage Plan will need after an acute injury, illness, or event, like a fall or a stroke. Post-acute care can include things like therapy and skilled care from home health agencies, skilled nursing homes, and inpatient rehabilitation centers.

It’s unclear how nH Predict works exactly, but it reportedly estimates post-acute care by pulling information from a database containing medical cases from 6 million patients. NaviHealth case managers plug in certain information about a given patient—including age, living situation, and physical functions—and the AI algorithm spits out estimates based on similar patients in the database. The algorithm estimates medical needs, length of stay, and discharge date.

But Lynch noted to Stat that the algorithm doesn’t account for many relevant factors in a patient’s health and recovery time, including comorbidities and things that occur during stays, like if they develop pneumonia while in the hospital or catch COVID-19 in a nursing home.

According to the Stat investigation and the lawsuit, the estimates are often draconian. For instance, on a Medicare Advantage Plan, patients who stay in a hospital for three days are typically entitled to up to 100 days of covered care in a nursing home. But with nH Predict, patients rarely stay in nursing homes for more than 14 days before receiving payment denials from UnitedHealth.

When patients or their doctors have requested to see nH Predict’s reports, UnitedHealth has denied their requests, telling them the information is proprietary, according to the lawsuit. And, when prescribing physicians disagree with UnitedHealth’s determination of how much post-acute care their patients need, their judgments are overridden.

Favorable failings

The use of faulty AI is not new for the health care industry. While AI chatbots and image generators are currently grabbing headlines and causing alarm, the health care industry in the US has a longer record of problematic AI use, including establishing algorithmic racial bias in patient care. But, what sets this situation apart is that the dubious estimates nH Predict spits out seem to be a feature, not a bug, for UnitedHealth.

Since UnitedHealth acquired NaviHealth in 2020, former employees told Stat that the company’s focus shifted from patient advocacy to performance metrics and keeping post-acute care as short and lean as possible. Various statements by UnitedHealth executives echoed this shift, Stat noted. In particular, the UnitedHealth executive overseeing NaviHealth, Patrick Conway, was quoted in a company podcast saying: “If [people] go to a nursing home, how do we get them out as soon as possible?”