A class-action lawsuit was filed against Humana Inc. (NYSE: HUM) in Kentucky on Tuesday. The company is the latest insurer under fire over its alleged utilization of AI to dictate or deny post-acute care.
Humana Medicare Advantage (MA) beneficiaries, specifically, filed the lawsuit, alleging that the company illegally used algorithms to limit post-acute care services. The algorithm tool in question is known as “nH Predict.”
Based in Louisville, Humana is one of the largest insurers in the country. It has nearly 6 million MA beneficiaries. The company also owns CenterWell Home Health, one of the largest home health providers in the country.
“Humana systematically deploys the AI algorithm to prematurely and in bad faith discontinue payment for healthcare services for elderly individuals with serious diseases and injuries,” the lawsuit read. “These elderly patients are left either with overwhelming medical debt, or without the medical care that they require.”
After STAT News conducted an investigation into Medicare Advantage insurers and their use of algorithms to deny payment for care, multiple class-action lawsuits have been filed.
Most recently, a lawsuit was filed against UnitedHealth Group over the denial actions of its convener – naviHealth – in Minnesota. Cigna was also hit with a class-action lawsuit in Connecticut over claim denials made via its PxDx tool.
Home health patients are affected by these denials, as are providers. Providers have long griped about “middlemen” conveners affecting care and payment for that care.
“We have all of the capabilities conveners have,” Chris Gerard, the former CEO of Amedisys Inc. (Nasdaq: AMED), told Home Health Care News in 2022. “The one thing they can do for plans that we’re not going to do is manage a network of providers. We can absolutely do what they do when it comes to utilization management. We can get the same outcomes. We can drive savings for the plan. [Given that], it absolutely makes no sense for us to work with [them].”
The lawsuits also shine a spotlight on AI usage in health care generally. AI is already nearly ubiquitous across health care settings, but its newness is evoking ethical questions.
The aforementioned AI tools’ denial of claims have, in some instances, allegedly forced patients to pay thousands of dollars out of their own pockets for care.
Humana told Home Health Care News that it “does not comment on pending litigation,” but did elaborate on its use of “augmented intelligence.”
“I can confirm that at Humana, we use various tools, including augmented intelligence, to expedite and approve utilization management requests and ensure that patients receive high-quality, safe and efficient care,” a Humana spokesperson said. “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. It’s important to note that adverse coverage decisions are only made by physician medical directors.”