TRAVERSE CITY, MI (Michigan News Source) – In today’s health care maze, the call on when you’re “well enough” to leave rehab may come from a computer, not your doctor. A federal class-action lawsuit filed December 12, 2023, claims Humana uses an algorithm in its Medicare Advantage plans to overrule physicians and decide when elderly patients are discharged from care.
At the center of the case is a tool called nH Predict, a program developed by naviHealth and now owned by UnitedHealth Group. Insurers like Humana and Cigna contract it out to estimate how long a patient “should” need rehabilitation. Instead of weighing individual medical needs, the software spits out an average recovery time based on algorithms.
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The problem, according to the lawsuit, is that recovery doesn’t always follow a spreadsheet. Patients are often still in pain, still on catheters, or still unable to walk when coverage is cut. The suit calls it “Humana’s illegal deployment of artificial intelligence (AI) in place of real doctors to wrongfully deny elderly patients care owed to them.”
Profit over patients.
The complaint paints a simple strategy where the plaintiffs allege that Humana denies care, pockets the savings, and assumes most patients are too sick or exhausted to fight back. It notes that fewer than 0.2% of patients appeal coverage denials – even though appeals succeed nearly 90% of the time. In practice, that means the AI is wrong often, but insurers profit anyway.
While Medicare Advantage plans can and typically cover up to 100 days in a nursing facility after a three-day hospital stay, the lawsuit claims the AI tool often pulls the plug after about two weeks. For patients recovering from strokes, surgeries, or serious injuries, that premature cutoff can be devastating. The result: patients either go without the care their doctors prescribed or they or their families are left footing the bill out of pocket.
Humana’s response.
Humana, which provides Medicare Advantage coverage to more than 5 million Americans, denies the accusations made in the lawsuit. The company insists it does not rely solely on AI to make decisions, saying human reviewers are always involved and that all denials of post-acute care were made on an individualized basis by physician medical directors.
Additionally, they argue in a September 12 answer to an amended complaint that the plaintiffs’ case shouldn’t even be in federal court because the claims are preempted by federal law and the plaintiffs failed to exhaust mandatory Medicare administrative remedies before suing. Amazingly, they also argue that plaintiffs didn’t suffer “real injuries” or a financial loss caused by Humana.
Traverse City senior in limbo.
A case mirroring the class-action lawsuit against Humana is unfolding in Traverse City right now, where an 80-year-old woman – who asked that her name be withheld – is facing the same struggle.
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After spine surgery, she entered a rehab facility to relearn how to walk and live safely alone in her home, with her doctors recommending continued therapy.
But Humana, her insurer, had other plans. Despite her physicians’ orders, coverage was abruptly terminated. Now she’s stuck appealing the denial repeatedly, trying to stay long enough to regain her independence. She is not asking for special treatment she says. She just wants to leave rehab on her own two feet, not in a wheelchair. Her family, strong advocates for her care, have gotten letters from her doctors and surgeon to use in her appeals and await Humana’s next decision.
The bigger picture.
Humana isn’t alone though. UnitedHealth and Cigna face similar lawsuits, with allegations that Cigna denied more than 300,000 claims in just two months. A U.S. Senate report had flagged high rejection rates among the nation’s three largest Medicare Advantage insurers in October 2024, warning that reliance on algorithms could violate federal law requiring individualized medical decisions.
The report found that the companies not only ramped up prior authorization denials but also sharply increased their rejection rates for post-acute care services.
Senator Richard Blumenthal (D-Conn), Chair of the Permanent Subcommittee on Investigations said, “I want to put these companies on notice. If you deny lifesaving coverage to seniors, we’re watching, we will expose you, we will demand better, we will pass legislation if necessary, but action will be forthcoming.” For all the fiery warnings, however, Congress has yet to deliver real reform.
October hearing will shape the legal battlefield.
Judges have denied Humana’s motion to dismiss and have allowed the Humana case to move forward, with a conference scheduled for October 2 before U.S. Magistrate Judge Colin H. Lindsay. The meeting will potentially set deadlines, discovery plans, and possibly explore settlement.
For the Traverse City woman – and thousands like her (if not more) – the fight is personal. Doctors say she still needs help. The computer says she doesn’t. So she remains in limbo, an unwilling test case in a health care system where recovery is measured not by healing, but by algorithms and profit margins.
