UNCOVERING AI-DRIVEN DENIALS: LAWSUIT ALLEGES UNITED HEALTH'S ROLE IN HARM TO ELDERLY PATIENTS

In a recent legal battle, two families are accusing United Health Group of utilizing artificial intelligence (AI) to reject or curtail rehabilitation stays for two elderly individuals, affecting their health outcomes. The families argue that United Health's AI is making inflexible and impractical determinations regarding patients' recovery, leading to denied care in skilled nursing and rehab centers covered under Medicare Advantage plans. This federal lawsuit challenges the legality of allowing AI to supersede doctors' recommendations and asserts that such assessments should remain within the purview of medical professionals.

 

AI's Unsettling Impact on Elderly Care

The families contend that United Health is withholding care from vulnerable elderly patients who may not actively contest these decisions. Despite evidence suggesting a subpar performance by the AI in assessing patients' needs, the company relies on algorithms to shape coverage plans, often overriding doctors' recommendations. Shockingly, the lawsuit reveals a staggering error rate in the AI program, with over 90% of patient claim denials being overturned through appeals. However, most patients opt not to challenge these algorithmic determinations, leaving them to bear out-of-pocket costs or forgo prescribed post-acute care.

 

Profit Over Patients: Allegations Against UnitedHealth

Legal representatives for the suing families argue that United Health prioritizes its profits over its contractual obligations to provide coverage. Ryan Clarkson, a California attorney involved in several AI-related cases, bluntly states, "It's just greed." The lawsuit sheds light on the insurance company's strategy, emphasizing the high rate of denials as part of a profit-driven approach.

 

United Health counters these allegations, asserting that NaviHealth's AI program, referenced in the lawsuit, serves as a guide rather than making coverage determinations. The company claims that decisions are based on the criteria set by the Centers for Medicare & Medicaid Services and the consumer's insurance plan.

 

Challenging the Denials: Families Pay the Price

The plaintiffs in this lawsuit are the families of Gene B. Lokken and Dale Henry Tetzloff, both insured by United Health's private Medicare plans. Lokken, aged 91, experienced a fall at home in May 2022, leading to a brief hospital stay and subsequent rehabilitation. Despite a doctor's recommendation for continued therapy, Lokken's coverage was terminated prematurely. The family chose to continue therapy, incurring significant out-of-pocket expenses. Lokken passed away in July 2023.

 

Tetzloff, recovering from a stroke in October 2022, faced similar challenges. Despite doctor-recommended rehabilitation, the AI algorithm sought to end coverage prematurely. The family's appeals prolonged the coverage but were insufficient. Tetzloff's family had to bear over $70,000 in care costs over the following months, and he passed away in assisted living in October 2023.

 

A Growing Trend in Legal Battles

This lawsuit adds to a growing body of litigation challenging the use of AI in healthcare decisions. Similar cases have been filed against other entities, including CIGNA Healthcare, OpenAI (maker of ChatGPT), and Google. The legal landscape indicates a rising concern about the role of AI in shaping critical decisions affecting individuals' health and well-being.

 

The Need for Human Oversight in AI

As AI technology becomes more prevalent in healthcare, legal experts stress the importance of human oversight in decision-making processes. While AI can efficiently handle routine tasks, its potential for errors and lack of common sense necessitates human involvement. The lawsuit against United Health underscores the significance of ensuring that AI systems allow for human intervention and discretion, especially in cases involving healthcare decisions.

 

Gary Marchant, faculty director at the Center for Law, Science, and Innovation at Arizona State University, emphasizes the need for a "human in the loop." Companies deploying AI, particularly in healthcare, should carefully consider the balance between algorithmic efficiency and the potential for mistakes. The legal scrutiny faced by United Health highlights the importance of providing opportunities for human decision-makers to override AI algorithms, a critical factor in navigating the intersection of AI and healthcare.

 

In conclusion, the lawsuit against United Health brings to light the intricate ethical and legal challenges posed by the increasing use of AI in healthcare decision-making. As technology evolves, striking the right balance between efficiency and human oversight remains paramount to ensure fair and just outcomes for patients.