UnitedHealthcare accused of relying on AI algorithms to deny Medicare Advantage claims

Democrats in a Senate subcommittee accuse UnitedHealthcare Group of denying the claims of a growing number of patients as it attempted to leverage artificial intelligence to automate the process.

In an October report titled “How Medicare Advantage Insurers Denied Patients Access to Post-Acute Care,” Democrats on the U.S. Senate Permanent Subcommittee on Investigations (PSI) released a report claiming that the rate UnitedHealthcare's prior authorization denial rate for post-acute care increased from 10.9 to 10.9. % in 2020 to 22.7% in 2022.

Refusal rates from skilled nursing centers, in particular, “have seen particularly dramatic growth.” The number of applications denied in 2022 was nine times higher than in 2019, according to the report.

During that same period, the company “implemented several initiatives to automate the process,” according to the report.

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The report also claims that United “processed significantly more authorizations for home health services for Medicare Advantage members during this period, highlighting concerns about insurers' rejection of placements in post-care facilities.” acute in favor of less costly alternatives,” the report states.

FOX Business has contacted United for comment. In a statement released in October, the company blasted the report, saying it “misrepresents the Medicare Advantage program and our clinical practices, while ignoring CMS criteria requiring greater scrutiny of post-acute care.”

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Report emerges as largest health report insurance company has come under fire for allegedly falsely denying claims in recent months. The killing of UnitedHealthcare CEO Brian Thompson in New York on Wednesday prompted more critics to voice their frustrations with the company.

A UnitedHealthcare sign is displayed in front of a store in the Queens borough of New York on January 14, 2013. (Michael Nagle/Bloomberg via Getty Images / Getty Images)

According to the PSI report, a UnitedHealthcare committee approved the use of “machine-assisted prior authorization” to expedite the medical claims review process in April 2021. The committee was told that doctors or nurses had yet to verify the evidence, but tests showed the technology could cut review time by 6 to 10 minutes, the report said.

UnitedHealthcare tested a new “HCE automatic authorization model” in early 2021, and internal meeting notes found it produced “faster processing times” for cases. But there was also an increase in the number of cases denied due to the system catching missed errors during the initial review, according to the report. The report said the committee voted to tentatively approve the model at a meeting a month later.

In December 2022, a group at UnitedHealthcare explored how to use AI and “machine learning” to predict which post-acute care denials were likely to be appealed and which of those appeals were likely to be appealed. 'be canceled.

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This 2017 file photo of Brian Thompson was published via Businesswire when he was named CEO of UnitedHealthcare in 2017. (Businesswire/Fox News)

Nearly a year later, in November 2023, the nation's largest insurance company was hit with a class-action lawsuit accusing it and its subsidiary NaviHealth of relying on a computer algorithm to “systematically deny claims” of Medicare beneficiaries in nursing homes who have struggled to recover from debilitating illnesses.

The suit claimed the company illegally deployed “artificial intelligence (AI) in place of real healthcare professionals to wrongly deny elderly patients the care they are owed under Medicare Advantage plans by canceling the their treating physicians' determinations of medically necessary care based on an AI model. ”

The suit also claimed the company knew this model “had a 90% error rate.”

Prescription pills in US dollars (iStock/iStock)

The suit goes on to argue that despite the high error rate, the company and its subsidiary “continue to systematically deny claims using their flawed AI model” because they know that only about 0.2% of policyholders will actually appeal denied claims and the vast majority will do so. pay out-of-pocket costs or forgo the remainder of prescribed post-acute care.

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“The defendants rely on the patients' health status, their lack of knowledge and the lack of resources to appeal erroneous decisions based on AI,” the trial continued.

The complaint was filed shortly after a Stat News investigation found that UnitedHealth pressured employees to use an algorithm to disrupt rehabilitation care for Medicare patients.

The investigation found that the algorithm predicted the patient's length of stay in order to deny payments to people with Medicare Advantage plans.