Legal Battle Unveils Allegations of AI-Driven Healthcare Denials

Two families have filed a landmark lawsuit against UnitedHealth Group, claiming that the insurance company unfairly refused or curtailed rehabilitation stays for their elderly loved ones owing to the company’s use of artificial intelligence (AI). A federal complaint filed in Minnesota claims that UnitedHealth’s AI is unilaterally and unjustly withholding coverage for skilled nursing and rehab institutions under Medicare Advantage plans.  

The families think that healthcare choices should be made by doctors, not technology. According to the reasoning, AI is making this assertion. The estates of two elderly Wisconsin men who brought the case are pursuing class-action status to highlight the illegality of enabling AI to overturn critical medical decisions for individuals.  

They claim that UnitedHealth discriminates against the elderly since they cannot appeal AI findings. Despite figures revealing a significant mistake rate in the AI program, the corporation appears to use algorithms to design coverage plans and reject medical suggestions.  

According to court documents, the majority of claims that were first denied for patients were eventually paid after an internal appeal or review by a federal administrative law judge. However, because just 2% of patients chose to appeal claim denials, the vast majority were forced to pay for post-acute care out of pocket or go without it.  

In court, families’ representatives said that UnitedHealth is more concerned with profits than with the people it is intended to serve. UnitedHealth responded by rejecting the charges and claiming that their artificial intelligence (AI) platform, naviHealth, is a vital resource for training doctors, family members, and other caregivers on how to provide the best possible care to their patients.  

This is the latest in a series of lawsuits challenging the use of artificial intelligence in healthcare decision making. The Clarkson legal firm, which represents the families, has previously filed a lawsuit against CIGNA Healthcare, OpenAI, and Google for allegedly utilizing AI to automate claim denials. Gene B. Lokken and Dale Henry Tetzloff both had private Medicare insurance through UnitedHealth, and their families are suing the firm.

The case describes how the families of Lokken, who collapsed at home, and Tetzloff, who was recuperating from a stroke, were put in financial jeopardy due to the denial of critical rehabilitation therapy. This legal action stems from Medicare advocates’ growing concern about the widespread use of AI technology to refuse or limit care for older persons on private Medicare plans.

The Center for Medicare Advocacy did a study in 2022 that found AI algorithms frequently make overly simplified coverage determinations without a comprehensive review of each particular circumstance. The scenario raises ethical concerns about employing algorithms to make health care choices and gives insight into the potential ramifications of doing so. 

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This was published by USA Today