Fourth Largest Health Insurer U.S. Is Sued For Fraudulent, AI-Calculated Denial of Claims

rredick March 12, 2024

Photo credit: UnitedHealth Group

If you’ve been thinking that concerns about artificial intelligence are overblown, this story may change your mind. But as with many abuses of new technology, human greed also plays a role.

If one were to compile a list of Very Worst Things To Automate, decisions about how much health care a person will need in the future would be right up there with infant births and love letters. But that’s exactly what UnitedHealth, the fourth largest health insurer in the U.S., is accused of doing.

According to the plaintiffs in a November lawsuit, UnitedHealth used an AI-driven algorithm to predict how long patients in various rehabilitation programs would need to stay. When patients stayed longer, coverage was denied. The algorithm took precedence even over doctors’ recommendations and blatant evidence of continuing need.

Not only is UnitedHealth alleged to have saved many millions through such automated denial of coverage claims, but it is also beleived to have reduced its operating costs dramatically by using software, rather than human employees, to review claims and issue decisions.

The financial incentive for such mass denial of coverage is not hard to grasp. Less obvious perhaps is the fact when patients appeal the software-driven decision, over 90% of those appeals are successful.

So why is denial of coverage so lucrative? The answer’s simple: patients don’t know they can prevail. Despite the overwhelming success rate of those who do appeal, only .2% of those denied coverage make the attempt.

This is grim but important reading. We hope your Loved Ones never receive such treatment.

https://www.healthcaredive.com/news/unitedhealth-algorithm-lawsuit-care-denials/699834/

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