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The deadly UnitedHealthcare shooting (UNH-5.17%) CEO Brian Thompson on Wednesday sparked public scrutiny of health insurers, particularly regarding their use of AI in evaluating claims. The incident also comes as several insurers face litigation over their coverage practices and the potential impact they have on patient care.
Thompson was fatally shot in New York on Wednesday morning, just hours before his speech at the insurance company’s annual investor day.
Several media outlets reported Thursday that shell casings from the shooting bore the words “deny”, “defend” and “depose” written on it. The words seem terms of reference Industry critics use it to describe how insurers deny claims.
At the same time, social media posts claim that UnitedHealthcare’s claim denial rate is the highest the highest in the industry; However, as insurers attempt to keep these figures hidden, the true extent of these denials remains unclear, especially when it comes to private plans.
However, some recent reports show that refusals from some patients are increasing.
In October, a report of the US Senate Permanent Subcommittee on Investigations showed that insurers nationwide used AI-based tools to deny certain claims from Medicare Advantage plan subscribers.
The report finds that UnitedHealthcare’s denial rate for post-acute care (health care needed to get people out of hospitals and back into their homes) for people with Medicare Advantage plans increased to 22.7 % in 2022, compared to 10.9% in 2020.
This increase coincides with UnitedHealthcare’s implementation of an AI model called nH Predict, originally developed by naviHealth, a subsidiary of UnitedHealth Group that has since been renamed.
Algorithms like nH Predict can analyze millions of data points to generate predictions and recommendations by comparing patients to others with seemingly similar characteristics, a study shows. JAMA Network article. However, the article cautions that claims of increased accuracy through advanced computational methods are often exaggerated.
Both UnitedHealth And Human are currently facing legal action for their use of nH Predict. The lawsuits allege that insurers pressured case managers to follow the algorithm’s length of stay recommendations, even when clinicians and families objected.
A lawsuit filed last year against UnitedHealth claims that 90% of the algorithm’s recommendations are overturned on appeal.
The lawsuit says UnitedHealthcare wrongly denied care to elderly patients by “overruling their treating physicians’ determinations about medically necessary care based on an AI model that defendants know has an error rate of 90%.”
In court filings, UnitedHealth attorneys argued that the lawsuit should be dismissed because the plaintiffs failed to successfully complete Medicare’s appeals process and that their grievances were against the federal government and not UnitedHealth. STAT News reported in May.
UnitedHealthcare and Humana (HUM-3.23%) did not immediately respond to Quartz’s requests for comment.
Cigna (IC-5.13%) is also facing lawsuits for its use of a separate algorithm to reject insurance claims. A Trial 2023 alleges that the company uses its PxDx system to analyze and deny claims in bulk before forwarding them to physician reviewers for final approval. Cigna relies heavily on the automated system, allowing claims to be denied without any review of individual patient records, according to the complaint. He cites a ProPublica investigation revealing that a single medical director at Cigna rejected 60,000 requests in just one month.
Cigna also did not immediately respond to a request for comment from Quartz.