News of the Restless

Oh the horror! Oh the humanity! Headlines screamed: A cold-blooded murder in Manhattan! Insurance company CEO shot in the early morning, just as he was headed for an investor conference! Gunman still on the loose!

Well, I don’t know who the shooter is, but I think his motive for the (cough) crime he committed will be abundantly clear after you watch this short video:

Yes, that’s right — it’s DENIAL of coverage. And it gets even uglier when you see what’s behind that denial.

One criticism of UnitedHealthcare that has garnered attention following the shooting involves a lawsuit alleging the company uses artificial intelligence (AI) to deny coverage to some elderly patients who are on a Medicare Advantage plan, despite allegedly being aware that the algorithm has a 90 percent error rate.

The lawsuit was filed on November 14, 2023. It names UnitedHealth Group, UnitedHealthcare and NaviHealth as the defendants. It was brought by the families of two now-deceased patients who were denied coverage by UnitedHealthcare for stays at nursing homes. The suit is ongoing, and its claims have not been proved in court.

The lawsuit alleges the provider continues using the system because it knows that only about 0.2 percent of policyholders will appeal their denied claims and that the majority will “either pay out-of-pocket costs or forgo the remainder of their prescribed post-acute care.”

The suit says that UnitedHealthcare banks “on the patients’ impaired conditions, lack of knowledge, and lack of resources to appeal the erroneous AI-powered decisions.”

It goes on: “The fraudulent scheme affords Defendants a clear financial windfall in the form of policy premiums without having to pay for promised care, while the elderly are prematurely kicked out of care facilities nationwide or forced to deplete family savings to continue receiving necessary medical care, all because an AI model ‘disagrees’ with their real live doctors’ determinations.”

The suit says that an AI model was used to compare a patient’s diagnosis, age, living situation and physical function to similar patients to predict the person’s needs, estimated length of stay and target discharge date from care facilities.

That model, however, allegedly provided “generic recommendations” that did not “adjust for a patient’s individual circumstances and conflict with basic rules on what Medicare Advantage plans must cover,” according to the suit.

In May, UnitedHealth Group’s lawyers argued the suit should be dropped because the plaintiffs “failed to exhaust the exclusive administrative appeal process set by the Medicare Act,” reported the website Stat. They said the issues raised in the lawsuit are with the federal government, not UnitedHealth or its subsidiaries.

For instance, the lawsuit alleged that patients were “rarely” in a nursing home for more than two weeks before they started to receive payment denials, despite Medicare Advantage plans allowing patients who were in the hospital for three days to get up to 100 days in a nursing home.

The lawsuit also says that more than 90 percent of these denials that are appealed are ultimately reversed.

Moreover, US private insurers in general deny claims 16% of the time, on average; UnitedHealth was denying at least 32% of claims, double the industry average.

And that “ultimately reversed” only happens if people appeal in a timely manner. But a lot of them can’t, because they died as an immediate result of those denials. While an appeal may be timely for the insurer, it is far less so for the patient and their family. When some patients are even being wheeled out of operating rooms prematurely because the insurer won’t cover sufficient anesthesia for a proper completion of procedure, it’s safe to say that the real death panels are, and always have been, the bean-counters at corporate headquarters.

And in the case of UnitedHealth, those bean-counters are not only literally faceless, but not even human at all.

Did the shooter, or someone he knows and loves, get denied coverage for necessary healthcare by an AI bot? I don’t know that either, but I wouldn’t be the least bit surprised if that turns out to be the case. At the very least, it would explain why he Sharpie’d “deny”, “defend”, and “depose” on his shell casings.

And while I sure do hope he never gets caught — well, on the off chance that he does, and gets his day in court, I really want to hear everything he has to say about why he did it. I’m sure it will be more than enlightening.