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Showing posts with label Medicare Advantage. Show all posts
Showing posts with label Medicare Advantage. Show all posts

Friday, November 24, 2023

UnitedHealth faces class action lawsuit over algorithmic care denials in Medicare Advantage plans

Casey Ross and Bob Herman
Statnews.com
Originally posted 14 Nov 23

A class action lawsuit was filed Tuesday against UnitedHealth Group and a subsidiary alleging that they are illegally using an algorithm to deny rehabilitation care to seriously ill patients, even though the companies know the algorithm has a high error rate.

The class action suit, filed on behalf of deceased patients who had a UnitedHealthcare Medicare Advantage plan and their families by the California-based Clarkson Law Firm, follows the publication of a STAT investigation Tuesday. The investigation, cited by the lawsuit, found UnitedHealth pressured medical employees to follow an algorithm, which predicts a patient’s length of stay, to issue payment denials to people with Medicare Advantage plans. Internal documents revealed that managers within the company set a goal for clinical employees to keep patients rehab stays within 1% of the days projected by the algorithm.

The lawsuit, filed in the U.S. District Court of Minnesota, accuses UnitedHealth and its subsidiary, NaviHealth, of using the computer algorithm to “systematically deny claims” of Medicare beneficiaries struggling to recover from debilitating illnesses in nursing homes. The suit also cites STAT’s previous reporting on the issue.

“The fraudulent scheme affords defendants a clear financial windfall in the form of policy premiums without having to pay for promised care,” the complaint alleges. “The elderly are prematurely kicked out of care facilities nationwide or forced to deplete family savings to continue receiving necessary care, all because an [artificial intelligence] model ‘disagrees’ with their real live doctors’ recommendations.”


Here are some of my concerns:

The use of algorithms in healthcare decision-making has raised a number of ethical concerns. Some critics argue that algorithms can be biased and discriminatory, and that they can lead to decisions that are not in the best interests of patients. Others argue that algorithms can lack transparency, and that they can make it difficult for patients to understand how decisions are being made.

The lawsuit against UnitedHealth raises a number of specific ethical concerns. First, the plaintiffs allege that UnitedHealth's algorithm is based on inaccurate and incomplete data. This raises the concern that the algorithm may be making decisions that are not based on sound medical evidence. Second, the plaintiffs allege that UnitedHealth has failed to adequately train its employees on how to use the algorithm. This raises the concern that employees may be making decisions that are not in the best interests of patients, either because they do not understand how the algorithm works or because they are pressured to deny claims.

The lawsuit also raises the general question of whether algorithms should be used to make healthcare decisions. Some argue that algorithms can be used to make more efficient and objective decisions than humans can. Others argue that algorithms are not capable of making complex medical decisions that require an understanding of the individual patient's circumstances.

The use of algorithms in healthcare is a complex issue with no easy answers. It is important to carefully consider the potential benefits and risks of using algorithms before implementing them in healthcare settings.

Saturday, November 26, 2011

Texas Lawsuit Identifies Problems In Medicare Hospice Provisions

By Jordan Rau
Kaiser Health News Staff Writer
Originally published 11/16/11

A lawsuit filed in Dallas against one of the nation's largest hospice companies identifies how Medicare's payment methods can offer unintended financial incentives to inappropriately move patients from HMOs into hospice programs and then into hospitals.

In a complaint unsealed last week in a federal court, a former general manager of Vitas HealthCare Corp.'s San Antonio office alleged the company defrauded Medicare through a "conspiracy" with two HMO companies. Vitas and the companies have denied the allegations. The Department of Justice and the state of Texas have declined to join with the plaintiffs in the suit "at this time."

Here's how the complaint alleges the arrangement worked: Since Medicare Advantage pays HMOs monthly per-patient fees, the HMOs had a financial incentive to avoid chronically ill patients, who need lots of treatments. So the HMOs referred many of their chronically ill patients for hospice care at Vitas, which accepted them even though their conditions weren't considered terminal.

The entire story can be read here.