Humana Is Latest To Face Lawsuit for AI-Based Denials of Medicare Advantage Claims in Nursing Homes

In facing a class-action lawsuit for its use of artificial intelligence in denying claims for services to residents in post-acute care, Humana (NYSE: HUM) joins the ranks of other health insurance behemoths such United Healthcare and Cigna.

The complaint, filed late Tuesday, in a federal court in Kentucky, accuses Humana of using AI tools – instead of doctors’ recommendations – to deny medically necessary care to residents under Medicare Advantage Plans.

“Humana systematically deploys the AI algorithm to prematurely and in bad faith discontinue payment for healthcare services for elderly individuals with serious diseases and injuries. These elderly patients are left either with overwhelming medical debt, or without the medical care that they require,” the lawsuit notes.


As with last month’s lawsuit filing against United Healthcare, a unit of UnitedHealth Group (NYSE: UNH), the complaint against Humana also notes the use of the same algorithm, which was created by UnitedHealth’s subsidiary NaviHealth. That AI Model, known as nH Predict, was used to override physicians’ determinations despite knowledge that the nH Predict AI Model predictions are “highly inaccurate,” the complaint against Humana reads.

Moreover, it states that employees faced consequences if they departed from strict performance targets.

A spokesperson for Humana told Skilled Nursing News that clinicians are involved in coverage decisions, and AI tools are simply used for improving the process.


“At Humana, we use various tools, including augmented intelligence, to expedite and approve utilization management requests and ensure that patients receive high-quality, safe and efficient care. By definition, augmented intelligence maintains a ‘human in the loop’ decision-making whenever AI is utilized,” the spokesperson said via an emailed statement. “Coverage decisions are made based on the health care needs of patients, medical judgment from doctors and clinicians, and guidelines put in place by CMS.  It’s important to note that adverse coverage decisions are only made by physician medical directors.”

In the summer, a lawsuit accused Cigna Group (NYSE: CI) of using AI tools to reject thousands of claims tied to the use of its own unique algorithm.

One of the two plaintiffs named in the Humana lawsuit include an 86-year-old Minnesota woman who fell at home and fractured her leg. The lawsuit alleges that Humana stopped paying for her post-acute care after two weeks and refused to pay for the continued rehabilitation treatment her doctor ordered.

“Appeals were denied, and Humana deemed [this resident] ready to return home, despite being bedridden and using a catheter,” the lawsuit notes.

The resident was forced to pay out of pocket for a less expensive assisted living facility and suffered further deterioration of her condition, only to return home before her doctor deemed her medically ready to reseek services.

“Humana continues to systemically use this flawed AI model to deny claims because they know that only a tiny minority of policyholders (roughly 0.2%) will appeal denied claims,” the lawsuit notes.

Lawmakers, federal officials and provider organizations have also criticized health insurance providers for the large number of coverage denials under Medicare Advantage plans – and the opaqueness of the claims assessment process.

New federal rules will force MA plans to limit use of AI tools in making coverage decisions come January.

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