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

Democrats on a Senate subcommittee are accusing UnitedHealthcare Group of denying claims to a growing number of patients as it tried to leverage artificial intelligence to automate the process.

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

Denial rates for skilled nursing centers, in particular, "experienced particularly dramatic growth." The number of denied claims in 2022 was nine times higher compared to 2019, according to the report.

During this same period of time, the company "implemented multiple initiatives to automate the process," according to the report. 

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The report also claimed United "processed far more home health service authorizations for Medicare Advantage members during this period, underscoring concerns about insurers rejecting placements in post-acute care facilities in favor of less costly alternatives," the report said. 

FOX Business reached out to United for comment. In a statement issued in October, the company lambasted the report, saying it "mischaracterizes the Medicare Advantage program and our clinical practices, while ignoring CMS criteria demanding greater scrutiny around post-acute care."

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

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

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According to the PSI's report, a UnitedHealthcare committee approved using "Machine Assisted Prior Authorization" to speed up the process of reviewing medical requests in April 2021. The committee was told doctors or nurses still had to verify the evidence, but testing showed the technology could cut review time by 6-10 minutes, the report said.

UnitedHealthcare tested a new "HCE Auto Authorization Model" in early 2021, and internal meeting notes revealed that it produced "faster handle times" for cases. But there was also an increase in the number of cases that were denied due to the system catching errors that were missed in the original 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 UnitedHealthcare group explored how to use AI and "machine learning" to predict which denials of post-acute care cases were likely to be appealed and which of those appeals were likely to be overturned.

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Brian Thompson (UnitedHealthcare)

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 that had struggled to recover from debilitating illnesses. 

The suit claimed the company illegally deployed "artificial intelligence (AI) in place of real medical professionals to wrongfully deny elderly patients care owed to them under Medicare Advantage Plans by overriding their treating physicians’ determinations as to medically necessary care based on an AI model." 

The suit also claimed the company knew this model "has a 90% error rate." 

The suit continued arguing that despite the high error rate, the company and its subsidiary "continue to systemically deny claims using their flawed AI model" because they know that only about 0.2% of policyholders will actually appeal denied claims and that the vast majority will either pay out-of-pocket costs or forgo the remainder of their prescribed post-acute care. 

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"Defendants bank on the patients’ impaired conditions, lack of knowledge, and lack of resources to appeal the erroneous AI-powered decisions," the suit continued. 

The suit was filed shortly after an investigation by Stat News found that UnitedHealth pressured employees to use an algorithm that was aimed at cutting off rehab care for Medicare patients. 

The investigation found that the algorithm predicted the patient’s length of stay to deny payments for individuals with Medicare Advantage plans. 

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