Court Orders UnitedHealth to Disclose Documents in Medicare Advantage Case
A Minnesota federal magistrate judge has instructed UnitedHealth Group to submit a comprehensive array of documents in an ongoing legal case. This case involves allegations of improper denial of Medicare Advantage post-acute care benefits using an AI algorithm. The March 9 directive favored the plaintiffs by granting discovery requests in six out of seven categories.
This lawsuit, initiated in 2023 by the relatives of two deceased Medicare Advantage beneficiaries, involves UnitedHealthcare's application of nH Predict. This algorithm, developed by naviHealth, a subsidiary of Optum renamed Home & Community Care in 2024, is at the center of the controversy. Plaintiffs claim the tool improperly overruled doctors' clinical decisions, leading to premature denials of essential skilled nursing care. Optum disputes these claims, asserting that medical necessity is determined by qualified physicians, in accordance with CMS guidelines, not by AI.
An Optum spokesperson emphasized that nH Predict is intended to support care by assessing various patient health factors. It is used to assist clinicians and caregivers in planning recovery, the spokesperson clarified, adding that naviHealth does not employ generative AI.
Document Disclosure Requirements
The court's directive requires UnitedHealth to provide records dating back to January 2017. These documents include policies and procedures related to post-acute care claims, materials discussing nH Predict, and records about naviHealth’s acquisition concerning cost reductions in post-acute care. Additionally, UnitedHealth must produce performance assessments and compensation details for post-acute care coordinators, documents from its internal AI review board, and contact information for medical directors and coordinators linked to coverage denials within a group of 300 proposed class members nationwide.
The judge dismissed UnitedHealth’s attempt to restrict certain requests, including the argument that pre-2019 documentation was irrelevant since nH Predict was not deployed until July 2019. The judge stated that earlier records might provide important indirect evidence, noting a 2024 Senate investigation that observed a substantial increase in denial rates following the implementation of nH Predict and naviHealth.
Some plaintiff requests were denied by the court. These include requests for the source code and underlying medical guidelines of nH Predict, comprehensive financial records of UnitedHealth, general employee disciplinary documents, and information about internal investigations not directly related to nH Predict or post-acute care. UnitedHealth has a 21-day deadline to comply with the document production order.