NaviHealth nH Predict used to deny Medicare Advantage benefits

Released: 2013

nH Predict and similar tools are being used by insurance companies to determine whether patients enrolled in US Medicare Advantage programmes are worthy of care, and are driving the denial of benefits.

nH Predict is a proprietary assessment tool developed by US-based health technology company naviHealth (since acquired by UnitedHealth Group) to identify a custom treatment regimen and recommended care setting for each patient, including when they should be discharged from hospital. 

It does this by sifting through millions of medical records to match patients with similar diagnoses and characteristics, including age, preexisting health conditions, and other factors. Based on these comparisons, the algorithm anticipates what kind of care a specific patient will need and for how long. 

According to a March 2023 STAT investigation, nH Predict and other tools were being used 'to pinpoint the precise moment when they can shut off payment for a patient’s treatment,' particularly for the elderly and disabled, and the denials that followed 'are setting off heated disputes between doctors and insurers'.

It later emerged that NaviHealth clinicians were becoming increasingly concerned that their UnitedHealth bosses were letting nH Predict override their own medical expertise, and, STAT reported that NaviHealth managers insisted the algorithm was followed precisely so that payments could be cut off by the dates predicted. 

In November 2023, a class action lawsuit brought by the estates of two deceased people who were denied health coverage by UnitedHealth accused UnitedHealth Group and NaviHealth of illegally using nH Predict to deny rehabilitation care to seriously ill patients. 

The suit also accused nH Predict of 'blatant inaccuracy' and argued UnitedHealth should have been aware of its high error rate. It also pointed out that over 90 percent of denials were reversed when appealed.


Operator: Humana; CVS Health/Aetna; Priority Health; Security Health Plan; Select Medical; UnitedHealth Group
Developer: UnitedHealth Group; Cardinal Health; SeniorMetrix

Country: USA

Sector: Health

Purpose: Predict post-acute care needs

Technology: Prediction algorithm
Issue: Accuracy/reliability; Ownership/accountability

Transparency: Governance; Black box; Complaints/appeals


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Page info
Type: Incident
Published: June 2023
Last updated: November 2023