How insurance companies use AI to deny claims
On Point | Podcast
Deep Dive
Why did Christine Huberty notice an increase in denied claims for skilled nursing care under Medicare Advantage?
Huberty observed that patients, including those with severe conditions like strokes, were being denied care that would have been approved under traditional Medicare. This led to patients losing weeks of necessary therapy and potential loss of function.
How many people use Medicare Advantage in the U.S.?
Approximately 31 million people use Medicare Advantage, according to the Kaiser Family Foundation.
What is the name of the algorithm used by UnitedHealthcare to predict patient stays in nursing homes?
The algorithm is called NHPredict, developed by Senior Metrics and later acquired by NaviHealth.
How much money does NHPredict save UnitedHealthcare annually?
The algorithm is estimated to save UnitedHealthcare and other insurers billions of dollars a year by cutting costs in post-acute care, which is a significant expense for health insurance companies.
What percentage of denied claims are overturned upon appeal?
Over 90% of denied claims are overturned upon appeal, according to the lawsuit against UnitedHealthcare.
What is the current status of the class action lawsuit against UnitedHealthcare for its use of AI in claims adjudication?
The lawsuit is in the pretrial discovery process, with no trial date scheduled yet.
What was the 1% target rule for case managers at NaviHealth?
Case managers were instructed to keep patient stays in nursing homes within 1% of the number of days projected by the algorithm, limiting their discretion to deviate from the AI's recommendation.
Why does Dr. Ziad Obermeier believe the use of AI in health insurance claims is flawed?
Obermeier argues that the current use of AI eliminates human oversight, leading to unjust decisions. He also criticizes the incentive systems that reward adherence to algorithms rather than clinical judgment.
What potential improvements does Christine Huberty suggest for the use of AI in health insurance claims?
Huberty suggests that denials should only occur due to a change in the patient's condition, that treating medical professionals should have an override for denials, and that automatic denials should be stopped unless prompted by a change in condition.
What advice does Casey Ross give to individuals facing denied health insurance claims?
Ross advises individuals to know their rights, ask questions about the decision-making process, and appeal denials. He notes that overturn rates are high (80-90%) when appeals are pursued.
- Medicare Advantage claims denials
- AI involvement suspected
- Christine Huberty's comment to CMS
- Stat News investigation
Shownotes Transcript