Health insurers face scrutiny over claims denials
By Jarrod Fowler, MHA, FMA Director of Healthcare Policy and Innovation | Nov. 30, 2023

UnitedHealthcare (UHC) is facing a class-action lawsuit, which claims the company used artificial intelligence in lieu of medical reviewers to inappropriately deny Medicare Advantage patients access to post-acute treatment. The suit alleges that the AI model has an error rate of around 90%, given that 90% of such denials that are challenged internally or through a judge are reversed. The suit further alleges that UHC utilized this technology knowing that only a small minority of policyholders would appeal their denied claims due to their impaired condition, lack of knowledge, or lack of resources. This story has been covered in detail by multiple outlets, including Ars Technica and StatNews.

Meanwhile, according to an article published in Fierce Healthcare, the Minnesota attorney general is asking that the Centers for Medicare & Medicaid Services investigate Humana’s Medicare Advantage program for wrongfully denying claims and overcharging subscribers on numerous occasions.

As these stories are unfolding, Politico reports that a bipartisan group of lawmakers is expressing concern that some Medicare Advantage plans may be engaged in unscrupulous practices, such as denying care that traditional Medicare would have covered. Medicare Advantage plans have already come under scrutiny in recent years for having burdensome and potentially problematic prior authorization practices, which many policymakers have been seeking to reform through more oversight, transparency, and guardrails.

The Politico article cites multiple bodies of research that illustrate the problems patients and caregivers can encounter as a result of the prior authorization process. While it remains to be seen whether new regulatory or legislative actions will be taken, momentum for change appears to be building. That said, cost concerns and fierce lobbying by health insurers may influence the scope of any reforms that are enacted.