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Humana Faces Class-Action Lawsuit over AI-Driven Rehab Care Denials

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Mason Walker
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Humana Faces Class-Action Lawsuit over AI-Driven Rehab Care Denials

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Medicare Advantage beneficiaries have filed a class-action lawsuit against Humana, accusing the health insurance provider of illegally using an algorithm to terminate payments for rehabilitation care following serious illness or injury. This is the second lawsuit of its kind, following a STAT investigation, which has raised serious concerns about the use of algorithms in healthcare payment decisions and their potential impact on patient care and outcomes.

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Allegations Against Humana

Humana Inc., a major player in the health insurance market, is facing a class-action lawsuit over its alleged wrongful denial of patients' care. The lawsuit accuses the insurer of relying on an artificial intelligence (AI) model, the nH Predict, to make 'rigid and unrealistic' projections for post-acute care duration following an inpatient hospital stay. This underscores the risks associated with the use of AI in healthcare.

The nH Predict AI model has been accused of causing elderly patients to be wrongfully denied post-acute care coverage under their Medicare Advantage plans. The model allegedly generates inaccurate predictions and overrides real doctors' recommendations, leading to increased coverage denials. Consequently, Humana's use of the AI model has been claimed to result in financial gain for the insurer at the expense of patients.

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Class-Action Lawsuit Details

The lawsuit is seeking $3 billion in damages, alleging that Humana has limited its employees' discretion and disciplined or terminated those who deviate from the AI model's recommendations. Two women claimed they were forced to pay out-of-pocket costs for necessary treatment that should have been covered under their Medicare Advantage plans.

AI in Healthcare: A Growing Concern

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This class-action lawsuit against Humana is the latest case highlighting the growing concern over the use of AI in healthcare. UnitedHealthcare and BlueCross BlueShield are also under scrutiny for their alleged use of flawed algorithms that determine coverage limits for their Medicare Advantage customers. Allegedly, these algorithms decide when care can be cut off for seniors needing additional recovery time following a hospital stay.

These lawsuits could potentially result in patients recovering some of the money they paid in premiums and some of the out-of-pocket expenses incurred after coverage was denied. Furthermore, if successful, these lawsuits could force health insurance companies to change their practices regarding the use of AI in making coverage decisions.

Impact on the Healthcare Insurance Industry

This series of allegations and class-action lawsuits could potentially lead to significant changes in the healthcare insurance industry, particularly for Medicare Advantage plans. The lawsuits highlight the need for increased transparency and accountability in the use of AI in healthcare decision-making. Furthermore, they underscore the potential risks and challenges associated with relying heavily on AI for critical healthcare decisions, particularly those impacting patient care and financial outcomes.

As healthcare continues to evolve, the role of AI and its impact on patient care and healthcare decision-making will undoubtedly remain a contentious and important issue. These lawsuits against Humana and other major insurers serve as a stark reminder that while AI has the potential to greatly improve healthcare delivery and outcomes, it must be implemented and used responsibly and ethically.

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