Class actions by insureds/members against UnitedHealth and Cigna for their use of AI in mass denials of medically necessary care have been filed across the country in November. We will continue to see this impact managed care litigation.
Providers and members alike should carefully review agreements (including participation/service agreements and benefit plans) to ensure they are not inadvertently agreeing to the use of AI tools to their detriment in the future. We can be certain payers will be seeking amendments to allow the same.
According to the lawsuit, UnitedHealth has used an AI tool called nH Predict to review post-acute care claims since at least September 2019. The healthcare conglomerate's Optum subsidiary acquired the software's developer, NaviHealth, the following year. Medicare Advantage members appealed less than 1% of post-acute care denials since then, but 90% of those denials were reversed, the plaintiffs assert.
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