UnitedHealthcare's broken AI denied seniors' medical claims, lawsuit alleges
- Reference: 1700009953
- News link: https://www.theregister.co.uk/2023/11/15/unitedhealthcare_ai_medicine/
- Source link:
The [1]lawsuit [PDF], filed Tuesday in federal court in Minneapolis on behalf of the estates of two elderly men, alleges that at least since UnitedHealthcare's 2020 acquisition of post-acute care management firm Navihealth, the US health insurance giant has repeatedly and wrongfully refused to pay the healthcare claims of senior patients using their Medicare Advantage Plans, apparently using advice from a self-serving algorithm.
[2]Medicare Advantage is a privately-run, government-approved version of the federal Medicare program and provides health coverage for US citizens or residents who are age 65 or older. Presently, approximately 31 million people in the US rely on Medicare Advantage.
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Various [4]studies suggest both Medicare and Medicare Advantage have attractive points for [5]certain health issues , though an April 2022 [6]report [PDF] from the Inspector General of the US Department of Health and Human Services found that private Medicare Advantage programs deny 13 percent of service authorization requests that would have been approved by government-run Medicare.
[7]
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The complaint, brought by Clarkson Law Firm, alleges UnitedHealthcare unlawfully deployed an AI system with a 90 percent error rate that improperly overrode the recommendations of physicians regarding medically necessary post-acute care for the elderly, i.e. treatment following discharge from a hospital.
By invoking this technology, they are effectively using AI to throw the elderly out onto the street
"UnitedHealthcare is responsible for the health care needs of some of our most vulnerable populations," said Ryan Clarkson, managing partner of Clarkson Law, in a statement. "But by invoking this technology, they are effectively using AI to throw the elderly – our parents or grandparents – out onto the street."
The nH Predict AI Model allegedly produces generic care recommendations that fail to account for the individual needs of patients, and also conflicts with Medicare Advantage coverage rules while conveniently saving UnitedHealthcare money. And it's claimed that UnitedHealthcare has instructed its employees not to deviate from its AI model's predictions about appropriate care and that the medical biz disciplines or terminates those who do so.
[9]Hospital to test AI 'copilot' for doctors that jots notes on patient care
[10]Healthcare org with over 100 clinics uses OpenAI's GPT-4 to write medical records
[11]Google, you're not unleashing 'unproven' AI medical bots on hospital patients, yeah?
[12]Cigna sued for using software to deny healthcare insurance claims
"Under Medicare Advantage Plans, patients who have a three-day hospital stay are typically entitled to up to 100 days in a nursing home," the lawsuit claimed, citing an investigative [13]report from medical publication STAT earlier this year.
"With the use of the nH Predict AI Model, [UnitedHealthcare] cut off payment in a fraction of that time. Patients rarely stay in a nursing home more than 14 days before they start receiving payment denials."
The complaint stated that when patient claim denials are appealed internally or via a federal Administrative Law Judge, 90 percent of the nH Predict determinations are reversed.
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"This demonstrates the blatant inaccuracy of the nH Predict AI Model and the lack of human review involved in the coverage denial process," the lawsuit claimed, adding that nH Predict determinations are not communicated to patients' doctors and that when inquiries are made, UnitedHealthcare employees deny their requests and claim the decision information is proprietary.
UnitedHealthcare did not immediately respond to a request for comment. ®
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[1] https://regmedia.co.uk/2023/11/14/unitedhealthcare_complaint.pdf
[2] https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/your-coverage-options/compare-original-medicare-medicare-advantage
[3] https://pubads.g.doubleclick.net/gampad/jump?co=1&iu=/6978/reg_software/aiml&sz=300x50%7C300x100%7C300x250%7C300x251%7C300x252%7C300x600%7C300x601&tile=2&c=2ZVRQd9dF37egzxewDmt@uQAAAAQ&t=ct%3Dns%26unitnum%3D2%26raptor%3Dcondor%26pos%3Dtop%26test%3D0
[4] https://www.kff.org/medicare/issue-brief/medicare-accelerated-and-advance-payments-for-covid-19-revenue-loss-more-time-to-repay/
[5] https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/your-coverage-options/compare-original-medicare-medicare-advantage
[6] https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf
[7] https://pubads.g.doubleclick.net/gampad/jump?co=1&iu=/6978/reg_software/aiml&sz=300x50%7C300x100%7C300x250%7C300x251%7C300x252%7C300x600%7C300x601&tile=4&c=44ZVRQd9dF37egzxewDmt@uQAAAAQ&t=ct%3Dns%26unitnum%3D4%26raptor%3Dfalcon%26pos%3Dmid%26test%3D0
[8] https://pubads.g.doubleclick.net/gampad/jump?co=1&iu=/6978/reg_software/aiml&sz=300x50%7C300x100%7C300x250%7C300x251%7C300x252%7C300x600%7C300x601&tile=3&c=33ZVRQd9dF37egzxewDmt@uQAAAAQ&t=ct%3Dns%26unitnum%3D3%26raptor%3Deagle%26pos%3Dmid%26test%3D0
[9] https://www.theregister.com/2023/03/21/abridge_hospital_ai_doctor/
[10] https://www.theregister.com/2023/06/06/carbon_health_deploys_gpt4powered_tools/
[11] https://www.theregister.com/2023/08/08/google_senator_ai_health/
[12] https://www.theregister.com/2023/07/26/cigna_healthcare_insurance_ai/
[13] https://www.statnews.com/2023/03/13/medicare-advantage-plans-denial-artificial-intelligence/
[14] https://pubads.g.doubleclick.net/gampad/jump?co=1&iu=/6978/reg_software/aiml&sz=300x50%7C300x100%7C300x250%7C300x251%7C300x252%7C300x600%7C300x601&tile=4&c=44ZVRQd9dF37egzxewDmt@uQAAAAQ&t=ct%3Dns%26unitnum%3D4%26raptor%3Dfalcon%26pos%3Dmid%26test%3D0
[15] https://whitepapers.theregister.com/
This was predicted!
Holy carp!
I've finally gotten around to reading [1]Cory Doctorow's excellent "Radicalized" , a collection of 4 science fiction novellas, and the eponymous tale describes exactly this scenario!
Of course, in the book, victims are "radicalized", taking matters into their own hands rather than banding together to launch a class action suit -- but still! Prescient!
(And highly recommended.)
[1] https://en.wikipedia.org/wiki/Radicalized_(Doctorow_book)
Robots in charge?
I'm guessing that most Register readers would say the day when 'robots will take over' is long, long away. This is one step on that road. Not assembly-line type robots wielding anti-tank guns, but cosseted in the hollowed-out volcanoes of corporate giants.
Here is my law: If you as a professional get questioned, possibly in court, then you have to justify your decision. You can't say "the machine told me" or "that's our procedure" and still be a professional. But hey! You are pretending to be a professional with all the appropriate knowledge and judgemental skills... except you're not. So you're a fraud and going to prison.
And another thing. (I come from Britain so I apologise if this is obvious to the US contingent.) How is 'The weird and magic machine that can't be questioned' allowed to fester when it comes to a public service? (Lots of things fester in other places but they're theoretically accountable.)
(And another thing. Nobody on this side of the Atlantic knows who/what United Healthcare is. A government program? A sneaky upstart corporation? Or what? You might know but lots of us don't. Give us a small sentence, just two words even, of alignment.)
You Don't Need AI to Defraud Your Customers
...
if (rand() <= FUCKED_PERCENTAGE) print "Computer says, 'No'. Claim denied for case # ", ${casenum} "!";
...
... but it sounds more authoritative/believable-by-the-ignorant-masses if you add in your claim denial letter, "We use AI to help our staff review and evaluate claims."