A class action lawsuit was filed Tuesday against UnitedHealth Group and a subsidiary alleging that they are illegally using an algorithm to deny rehabilitation care to seriously ill patients, even though the companies know the algorithm has a high error rate. [...] The investigation [...] found UnitedHealth pressured medical employees to follow an algorithm, which predicts a patient's length of stay, to issue payment denials to people with Medicare Advantage plans. Internal documents revealed that managers within the company set a goal for clinical employees to keep patients rehab stays within 1% of the days projected by the algorithm.
nH Predict estimates how long a patient will need in a nursing home by matching them against similar patients. The complaint, filed in Minnesota in November 2023 and named for Gene Lokken, a 91-year-old who had passed away that July, alleges the estimate was used to cut off payment for care that doctors had said was still needed, and puts the tool's error rate at around 90 percent, taking that figure from how often denials were overturned on appeal. UnitedHealth's position is that the tool informs providers and families rather than deciding coverage, and that decisions follow Medicare criteria and plan terms. The case is still running. The detail that carries past this one company is the 1 percent target: an estimate stops being an estimate the moment staff are measured against it.
