UnitedHealth Exposed: How an Algorithm's Flaws Could Cost Lives in Medicare Care Denials

A recent lawsuit has thrown a spotlight on UnitedHealth Group and its subsidiary, NaviHealth. The core of the controversy? The alleged misuse of an algorithm to deny rehabilitation care to Medicare Advantage plan holders. Filed by the Clarkson Law Firm in California, this class action lawsuit represents families of deceased patients, claiming that UnitedHealth knowingly used a flawed algorithm, resulting in care denials for critically ill patients.

The Investigation and Lawsuit

This lawsuit follows an investigative report by STAT, which uncovered that UnitedHealth pressured medical employees to adhere to an algorithm predicting patients' rehabilitation stay lengths. The internal documents revealed a company goal to align patient stays within 1% of the algorithm's predictions. The lawsuit, filed in the U.S. District Court of Minnesota, accuses UnitedHealth and NaviHealth of systematically denying claims, leading to premature discharge from care facilities or significant financial burdens on families.

The Response from UnitedHealth

UnitedHealth, in response, has stated that the NaviHealth predict tool is not a basis for coverage determinations. Instead, it's purportedly used as a guide for care and assistance post-discharge. The company asserts that the lawsuit lacks merit and is prepared to defend itself vigorously.

The Impact of the Algorithm

The complaint details a shocking 90% error rate in the algorithm, dubbed nH Predict. It highlights a severe discrepancy between the algorithm’s recommendations and the actual care needs, as assessed by human medical professionals. The lawsuit alleges not only a breach of contract and good faith but also points to broader insurance law violations across multiple states.

Human Cost: The Stories of Lokken and Tetzloff

The lawsuit brings forward the distressing stories of two Wisconsin residents. Gene Lokken, after suffering a leg fracture, was denied necessary physical therapy, leading his family to pay about $150,000 for continued care. Dale Tetzloff, a stroke patient, faced similar denials and, along with his wife, shouldered $70,000 in care costs. Both patients eventually passed away, raising questions about the impact of such algorithmic decision-making on patient health outcomes.

Broader Implications

This case isn't just about UnitedHealth; it's a reflection of a growing trend in healthcare where algorithms play a critical role in decision-making. The implications of such practices on patient care, especially in vulnerable populations like the elderly, are profound and warrant a thorough examination.

The Way Forward

As we delve deeper into this issue, several questions arise. How do we balance the efficiency of AI with the need for human empathy and understanding in healthcare? What checks and balances are necessary to ensure algorithms aid, rather than hinder, patient care? And importantly, how do we protect the rights and well-being of patients within these evolving healthcare frameworks?

This lawsuit against UnitedHealth might just be the tip of the iceberg in a much larger conversation about technology, ethics, and healthcare. As we await the legal proceedings, one thing is clear: the need for a careful, human-centered approach in integrating AI into healthcare decisions.