Suing Over AI: Medicare Advantage Beneficiaries File Class-Action Lawsuit Against Humana

Allegations Against Humana

Medicare Advantage beneficiaries have filed a class-action lawsuit against Humana, one of the nation's largest private insurers. The lawsuit alleges that Humana illegally used an algorithm, the nH Predict, to prematurely cut off payment for rehabilitation care for patients after they suffered serious illnesses and injuries. It has been suggested that this was part of a scheme to deny claims to desperately sick people, forcing them to either give up treatment or pay thousands of dollars out of pocket.

The Use of Artificial Intelligence

The lawsuit accuses Humana of using artificial intelligence to override doctors' recommendations and deny care owed to elderly patients. It is claimed that the AI used by Humana is known to deliver predictions that are 'highly inaccurate.' This is the second lawsuit to be filed following a STAT investigation, which uncovered that Medicare Advantage insurers nationwide are using algorithms to cut off patients' rehab care, thus affecting their access to treatment.

Humana's Legal Battles

In addition to facing the class action lawsuit, Humana has sued the U.S. government, challenging a Biden administration policy that allows Medicare to reclaim billions of dollars from insurers for overcharges. Humana has argued that the Centers for Medicare and Medicaid Services failed to justify its more aggressive approach towards determining whether private Medicare Advantage plans for people aged 65 and older were overpaid. The insurance giant has labelled this rule as 'arbitrary and capricious' and warned of 'unpredictable consequences for Medicare Advantage organizations and the millions of seniors who rely on the Medicare Advantage program for their healthcare.'

Impact on Mergers and Acquisitions

This legal turmoil comes in the wake of a blocked merger between Humana and Aetna, which was primarily focused on Medicare Advantage. Federal judge John Bates sided with the Justice Department's argument that the deal would lessen competition for Medicare Advantage plans and individual health insurance sold in state marketplaces. The potential merger between Cigna and Humana was also called off due to a disagreement over price and financial terms. Cigna is now reportedly considering the sale of its Medicare Advantage business, which could bring in several billion dollars but may leave the company shut out of a growing part of the insurance business.

Conclusion

The ongoing legal battles surrounding Humana and other insurers highlight the complex issues involved in healthcare delivery, particularly in the context of Medicare Advantage. The use of artificial intelligence in healthcare decision-making is a growing trend, but its implications on patient care and healthcare costs are still being scrutinized. As the situation unfolds, it serves as a critical reminder of the importance of transparency and accountability in healthcare delivery, ensuring that patient care is not compromised in the pursuit of efficiency and profit.