Medicare Advantage is a version of Medicare that’s managed by private insurers instead of the federal government. Post-acute care includes a range of medical services, including treatment at inpatient rehab or skilled nursing facilities, commonly provided after a hospital stay.
The AI in question is called nH Predict. The lawsuit says it compares information on similar patients within “a database of six million patients it compiled over the years” to predict how long a specific person will require care.
But the suit claims the AI uses “rigid and unrealistic predictions” for patients’ recoveries.
“Humana knows that the nH Predict AI Model predictions are highly inaccurate and are not based on patients’ medical needs but continues to use this system to deny patients’ coverage,” it reads.
The suit says Medicare Advantage patients who are hospitalized for three days usually are eligible to spend as many as 100 days getting follow-up care in a nursing home.
“With the use of the nH Predict AI Model, Humana cuts off payment in a fraction of that time,” the suit claims. “Patients rarely stay in a nursing home more than 14 days before they start receiving payment denials.”
Humana spokesman Mark Taylor told LPM News the company does not comment on pending litigation.
But he did confirm Humana uses “augmented intelligence” as a tool.
“By definition, augmented intelligence maintains a ‘human in the loop’ decision-making whenever AI is utilized. Coverage decisions are made based on the health care needs of patients, medical judgment from doctors and clinicians, and guidelines put in place by CMS (Centers for Medicare and Medicaid Services),” he said in an emailed statement.
Taylor also said adverse coverage decisions, such as when Humana denies or stops providing payment for a specific medical service, “are only made by physician medical directors.”
The lawsuit against Humana was filed Tuesday in the U.S. District Court for the Western District of Kentucky.
It’s similar to a November case brought against UnitedHealth Group — the parent company of the insurer UnitedHealthcare and naviHealth, the firm that originally developed nH Predict.
Plaintiffs in both lawsuits are represented by Clarkson Law Firm. In the case against Humana, the named plaintiffs are two patients whom the suit says were improperly denied coverage by the Louisville-based insurer.
Attorney Ryan Clarkson, the firm’s founder, said he knows of families that paid tens of thousands of dollars out-of-pocket to get treatment for their loved one that should have been paid for by their insurance plan.
“What we’re asking Humana to do is to follow the law by making sure that their coverage decisions are not outsourced to an AI,” he said. “And that they’re having real medical professionals, as required under the law, make decisions about elderly patients’ care.”
Clarkson said they also seek financial restitution, through this class-action case, for affected patients in Kentucky and other states.
“Kentucky patients should be on high alert for any denials that they receive for any health insurance claims they make to Humana or other [insurance] carriers,” he said. “And they should scour the claim denial letters for any indication of nH Predict or naviHealth's tool being involved in the decision-making process.”
The lawsuit’s allegations against Humana include breach of contract and breach of “the implied covenant of good faith and fair dealing” in its insurance agreements with patients.
