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.
Databank
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
System
Legal, regulatory actions
Investigations, assessments, audits
STAT (2023). How UnitedHealth’s acquisition of a popular Medicare Advantage algorithm sparked internal dissent over denied care
STAT (2023). Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need
STAT (2023). Buyer’s remorse: How a Medicare Advantage business is strangling one of its first funders
Research, advocacy
Be a Hero Fund. Tell Biden: Stop Death by AI
Center for Medicare Advocacy (2022). The Role of AI-Powered Decision-Making Technology in Medicare Coverage Determinations
Lam T. et al (2022). Randomized Controlled Trials of Artificial Intelligence in Clinical Practice: Systematic Review
News, commentary, analysis
https://www.statnews.com/2023/05/17/senate-investigation-medicare-advantage-algorithms-denials/
https://www.statnews.com/2023/11/14/unitedhealth-class-action-lawsuit-algorithm-medicare-advantage
https://www.commondreams.org/news/biden-ai-medicare-advantage
https://medicalxpress.com/news/2023-10-feds-rein-software-limits-medicare.html
https://medicareadvocacy.org/ai-plus-ma-equals-bad-care-decisions/
https://www.theverge.com/23664533/medicare-advantage-healthcare-algorithm
Page info
Type: Incident
Published: December 2023