UnitedHealth Group faces a potential class-action lawsuit over its use of an artificial intelligence tool to allegedly deny post-acute care coverage to Medicare Advantage members.
Family members of two deceased UnitedHealthcare Medicare Advantage policyholders filed a lawsuit Tuesday in the U.S. District Court for the District of Minnesota and aim to represent a national class of similarly affected enrollees. The lawsuit alleges that the health insurance company breached its contracts with members, which resulted in unjust enrichment under federal law. The complainants also claim that UnitedHealthcare violated state laws in more than 20 jurisdictions.
UnitedHealth Group did not respond to an interview request.
According to the lawsuit, UnitedHealth has used an AI tool called nH Predict to review post-acute care claims since at least September 2019. The healthcare conglomerate's Optum subsidiary acquired the software's developer, NaviHealth, the following year. Medicare Advantage members appealed less than 1% of post-acute care denials since then, but 90% of those denials were reversed, the plaintiffs assert.
Lockridge Grindal Nauen PLLC and the Clarkson Law Firm, which represent the plaintiffs, also are leading a case that accuses Cigna of using algorithms to reject claims.
The complaint targeting UnitedHealth alleges that the late Gene Lokken and Dale Tetzloff, both of Wisconsin, failed to receive appropriate coverage for care following major medical incidents.
After a fall that resulted in a broken leg and ankle and a hospitalization in May 2022, the then-92-year-old Lokken transferred to a hospice facility on a doctor's recommendation, the complaint says. UnitedHealthcare cut off hospice coverage two months later after deeming it medically unnecessary and denied an appeal, according to the plaintiffs. Lokken's family spent as much as $168,000 out of pocket for him to remain at the hospice provider until his death four months ago, the lawsuit asserts.
Tetzloff had a stroke at age 74 in October 2022 and UnitedHealthcare denied coverage for 20 days of nursing home care he received, then rejected multiple appeals, the lawsuit claims. His family paid more than $70,000 as a result, according to the complaint. Tetzloff died last month.