Humana sued for inappropriate Medicare Advantage care denials

Humana is the latest of the Medicare Advantage insurers to be sued for using AI to systematically deny care inappropriately. Tina Reed reports for Axios on a class action lawsuit filed in Kentucky alleging that Humana violated its government contract and charging Humana with unjust enrichment as well as violating insurance laws in 22 states.

The lawsuit explains that the Humana AI model–NaviHealth–cut off rehabilitation benefits for patients without regard to their particular recovery trajectories. In one case, Humana denied plaintiff JoAnne Barrows more than two weeks of rehab therapy after she fractured her leg in her home. Her doctor had said she needed six weeks of rehab.

Overruling the opinion of patients’ treating physicians, the complaint alleges that Humana’s AI model relies on “rigid and unrealistic predictions for recovery.” And, Humana knew that it’s AI model for predicting patents’ recovery was ‘highly inaccurate.”

A similar suit was brought last month against UnitedHealth, which owns NaviHealth.

These lawsuits come on the heels of a series of independent government and non-governmental reports finding widespread and persistent inappropriate delays and denials of care and coverage in Medicare Advantage plans. The Centers for Medicare and Medicaid Services, which should be overseeing these health plans, lacks the resources and the power to hold them to account for their bad acts.

Here’s more from Just Care:

• UnitedHealth deprives members of critical rehabilitation care
• Corporate health insurers use NaviHealth algorithms to deny care in Medicare Advantage plans
• OIG finds widespread inappropriate care denials in Medicare Advantage
• 2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan
• Be a Hero tells Congress to end Medicare Advantage wrongful delays and denials of care