Humana has filed a motion to dismiss a class action lawsuit filed by two Medicare members who alleged the company used artificial intelligence to process post acute care claims determinations and were wrongfully denied coverage.
The insurer said in the motion it did not make the determinations through the use of AI. It also contends the enrollees did not complete all the required steps in the appeal process through the Medicare Advantage plan, a four-step process that ends with a potential review by the Medicare Appeals Council.
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The class action lawsuit was filed in December in the U.S. District Court for the Western District of Kentucky by two Medicare Part C enrollees who received their coverage through the Louisville, Kentucky-based insurer.
The suit alleges that Humana's use of AI to review claims is a breach of contract, allegedly resulting in members paying for insurance benefits without receiving them. The suit further alleged the company violated insurance laws across 22 states.
The motion also contends that if members want to appeal a decision given by the Medicare Appeals Council, they would need to file a lawsuit against the secretary of the Health and Human Services Department to challenge the ruling.
Additionally, the insurer alleges that the original lawsuit was filed specifically in Kentucky to take advantage of the state's laws, which it said is another reason the case should be dismissed, given the court does not have sufficient subject matter jurisdiction. The motion argues that the Medicare and Medicaid Act negates all of the state law claims made in the lawsuit, because the federal statutes supersede state laws in cases related to Medicare.
A Humana spokesperson said the company plans to continue denying allegations of any wrongdoing, and that claims the insurer uses AI to make coverage denials with no human intervention or oversight have no merit.
