Humana seeks dismissal of case that alleged it used AI in claims denials

UPDATED: March 25 at 5:27 p.m. ET

Humana is seeking to have a proposed class-action lawsuit that accuses the insurer of using AI in claims denials dismissed.

In a filing submitted last week in Kentucky federal court, Humana said the courts lack jurisdiction in the case as the members who initially filed suit have not completed the full appeals process over their claims. Medicare Advantage enrollees "exhaust a four-step mandatory administrative review process" before seeking relief in court.

"Plaintiffs seek to sidestep the exclusive administrative appeal process set by the Medicare Act," Humana said in the suit. "Indeed, both Plaintiffs have partially completed Medicare Part C’s exclusive administrative appeal process."

In addition, Humana said that should they clear all four steps and wish to launch a legal challenge against a coverage decision, they would need to file suit against the secretary of the Department of Health and Human Services, per regulations.

The insurer also said it does not use artificial intelligence to make decisions about post-acute care coverage, but even if it did, the case is invalid due to the lack of jurisdiction.

Humana added in the filing that the lawsuit is "heavily copied-and-pasted from a similar action filed by the same law firm against another Medicare Advantage Organization." NaviHealth, which created the nH Predict tool at the center of the suit, is owned by UnitedHealth Group's Optum, and has been cited in similar lawsuits filed against UnitedHealthcare.

"Plantiff's putative class complaint … includes sensationalized allegations that Humana makes post-acute care coverage determinations based solely on the output of an Artificial Intelligence program," the insurer said. "Plantiff's allegations are false."

A newly filed lawsuit alleges that Humana used artificial intelligence algorithms to deny key rehabilitation care for seniors.

The suit echoes similar allegations against UnitedHealthcare, and the two are the largest players in the Medicare Advantage market. The plaintiffs say that the insurer relied on naviHealth's nH Predict tool to make coverage determinations in long-term care.

The company, which is now a subsidiary of UnitedHealth Group's Optum, has also been at the center of lawsuits against UHC. The nH Predict algorithm projects how long a patient will need rehabilitative services based on "rigid and unrealistic predictions for recovery," according to the lawsuit.

"As such, Humana makes coverage determinations not based on individual patients' needs, but based on the outputs of the nH Predict AI Model, resulting in the inappropriate denial of necessary care prescribed by the patients’ doctors," the plaintiffs said in the suit. "Humana’s implementation of the nH Predict AI Model resulted in a significant increase in the number of post-acute care coverage denials."

A Humana spokesperson said the insurer does not comment on pending litigation.

In addition to questioning the algorithm's methodology itself, the lawsuit alleges that employees were pressured to keep up with the model's targets, facing discipline or termination if they did not do so.

The lawsuit was brought by two individual plaintiffs, but they say the affected class could "number in the thousands to millions."

One of the plaintiffs, 86-year-old JoAnne Barrows, was discharged to a rehabilitation facility in November 2021 after being hospitalized following a fall. She was under a non-weight-bearing order for six weeks due to a leg injury, according to the lawsuit.

Humana informed Barrows that she would cancel her coverage after just two weeks in the rehabilitation facility, according to the lawsuit, though she was to be non-weight-bearing for an additional month. She appealed the decision but was denied, forcing her family to pay out-of-pocket for the rehab she needed, according to the suit.

A lawsuit filed last month against UnitedHealth alleges that naviHealth's platform has a "90% error rate" and that the insurer continued to use it despite that fact because very few members appeal claims denials.

The lawsuits follow an investigation in STAT News published earlier this year examining how MA plans may deploy AI technology in claims denials.