UnitedHealth Faces Suit Over AI-Based Medicare Advantage Claim Denials

The estates of two Medicare Advantage plan enrollees are suing UnitedHealth Group over the use of an automated system for managing coverage for skilled nursing facility care, rehabilitation facility care and other forms of post-acute care.

The plaintiffs say the company’s nH Predict system is too rigid.

The plaintiffs filed the complaint in the U.S. District Court for the District of Minnesota and are seeking national class-action status.

In addition to UnitedHealth, the list of defendants includes a UnitedHealth health insurance subsidiary, UnitedHealthcare, and the subsidiary that runs the nH Predict system, naviHealth.

The plaintiffs have accused the defendants of breach of contract, unjust enrichment and violation of state good-faith requirements.

Representatives for UnitedHealth were not immediately available for comment.

The patients: One of the patients involved in the suit, Gene Lokken, was a 91-year-old man who broke his leg in May 2022, went to the hospital and later entered hospice care.

After covering three weeks of hospice care, UnitedHealth said Lokken should be discharged.

His family appealed and lost. Lokken had out-of-pocket care expenses ranging from $12,000 to $14,000 per month until July 17, when he died.