NaviHealth nH Predict used to deny Medicare Advantage benefits

Occurred: March 2023-

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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.

According to a 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. STAT also reported that NaviHealth managers insisted the algorithm was followed precisely so that payments could be cut off by the dates predicted. 


Operator: Humana Inc; 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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