The use of algorithms by insurance companies to determine the length of stay for patients in medical facilities has been a contentious issue, as highlighted by the experiences of Megan Bent and her family. After her father underwent brain surgery to remove a melanoma metastasis, UnitedHealth denied coverage for his continued care, citing safety concerns about him coming home. Despite the recommendations of his medical team, which included a neurosurgeon and physical therapist, UnitedHealth’s subsidiary NaviHealth insisted that he only needed a couple of weeks to recover.
Speaking at the STAT Breakthrough Summit in San Francisco, Bent shared her family’s frustrating experience with the denial of care for her father. The use of algorithms to predict patient care needs has been a common practice among Medicare Advantage insurers, including UnitedHealth, even after the company phased out the NaviHealth brand. This approach has led to coverage being cut off based on predetermined calculations, rather than the actual medical requirements of the patients.
In response to STAT’s investigation on this issue, UnitedHealth denied using AI algorithms to automatically deny claims and accused the publication of seeking to profit from unproven statements. However, the investigation, which was a Pulitzer Prize finalist, shed light on the challenges faced by patients and their families when insurance companies prioritize cost-cutting measures over quality care.
Christine Huberty, an attorney at the Center for Medicare Advocacy, also spoke at the summit, highlighting the prevalence of denials of care by Medicare Advantage plans using similar algorithms. She emphasized that stories like Bent’s were not uncommon, with insurers like UnitedHealth, Humana, and CVS Health denying a significant number of claims for post-acute care among Medicare Advantage members.
Bent’s father, Gary Bent, a former physics teacher known for his dedication to education, faced significant challenges in his recovery after brain surgery. Despite the medical team’s recommendation for months of care in a rehabilitation facility, UnitedHealth refused to cover the stay, leading to multiple denials and appeals. Eventually, Gary Bent was discharged prematurely, only to develop a bacterial meningitis infection that ultimately contributed to his passing in March of 2023.
The experiences shared by Bent and Huberty underscore the need for greater transparency and accountability in the use of algorithms by insurance companies to determine patient care needs. As the healthcare industry continues to grapple with issues of cost containment and quality of care, it is essential to prioritize the well-being of patients and ensure that decisions about their care are based on medical necessity rather than predetermined calculations. The Department of Justice has initiated a separate investigation into potential criminal Medicare Advantage fraud by UnitedHealth. This comes as a response to allegations of improper denials of claims related to AI tools used by the company to determine coverage.
According to reports, the Centers for Medicare and Medicaid Services are responsible for overseeing claims denials, but there have been concerns about the lack of transparency in the use of AI by UnitedHealth. The company has been accused of bypassing regulations by claiming that their denial decisions are not solely based on AI, even though the tools heavily influence the process.
Christine Huberty, a whistleblower who has brought attention to these issues, highlighted the frequency of denials triggered by AI tools. Despite the absence of specific references to the NaviHealth name or the NH predict tool, the pattern of denials remains consistent. Huberty emphasized the need for regulatory intervention to address these concerns and ensure accountability.
The impact of these denials goes beyond individual cases, as highlighted by another participant, Bent, who shared her family’s experience with the denial process. She expressed solidarity with others facing similar challenges and emphasized the importance of addressing these issues on a larger scale.
Overall, the ongoing investigations and discussions shed light on the complex issues surrounding Medicare Advantage fraud and the role of AI in claims denials. The need for transparency, accountability, and regulatory oversight is crucial to protect the rights of patients and ensure fair and ethical practices in the healthcare industry.
