How UnitedHealthcare and other insurers use AI to deny claims – Quartz

“In October, a report from the U.S. Senate Permanent Subcommittee on Investigations showed that the nation’s insurers have been using AI-powered tools to deny some claims from Medicare Advantage plan subscribers. The report found that UnitedHealthcare’s denial rate for post-acute care — health care needed to transition people out of hospitals and back into their homes — for people with Medicare Advantage plans rose to 22.7% in 2022, from 10.9% in 2020.

“The rise coincides with UnitedHealthcare’s implementation of an AI model called nH Predict, originally developed by naviHealth, a subsidiary of UnitedHealth Group that has since been rebranded. Algorithms like nH Predict can analyze millions of data points to generate predictions and recommendations by comparing patients to others with apparently similar characteristics, according to an article on JAMA Network. However, the article cautions that claims of enhanced accuracy through advanced computational methods are often exaggerated…”

So, if health insurance company hired a consultant to develop algorithms that randomly or intentionally denied claims for care that could have prevented death or injury of Americans covered by a government or employer health plan, exactly who, if anyone, would be legally liable for damages – and how much? What kind of evidence and expert witnesses might be presented to a court?  Given legal remedies available, who could afford to sue?

Things change and stay the same:

ERISA and Variation in California Health Plan Consumer Protections – CA HealthCare Foundation

Employee Health Plan Protections Under ERISA – HealthAffairs

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