UnitedHealth Faces Suit Over AI-Based Medicare Advantage Claim Denials

The other patient, Dale Henry Tetzloff, was a 74-year-old man who had a stroke in October 2022. He received care in a hospital and then entered a skilled nursing facility.

After Tetzloff was in the facility for 20 days, UnitedHealth denied further coverage for facility care.

Tezloff and his wife appealed but lost. Tetzloff entered an assisted living facility and lived there until Oct. 11, when he died. His out-of-pocket expenses averaged $7,000 per month for 10 months.

The nH Predict System: The nH Predict artificial intelligence model compares information about a patient’s diagnosis, age, living situation and physical function with a database of 6 million patient records.

The system then uses the comparison to predict patients’ medical needs and expected discharge dates, according to the complaint.

The model “spits out generic recommendations that fail to adjust for a patient’s individual circumstances and conflict with basic rules on what Medicare Advantage plans must cover,” the plaintiffs assert.

The plaintiffs cite allegations in a STAT news article that UnitedHealth required workers to hold stays in skilled nursing facilities to within 1% of the days projected by the AI model.

“Employees who deviate from the nH Predict AI Model projections are disciplined and terminated, regardless of whether a patient requires more care,” the plaintiffs assert.

Credit: UnitedHealth