Denied by AI: How Medicare Advantage Plans Use Algorithms to Cut Off Care for Seniors in Need

This STAT investigation at the intersection of artificial intelligence and medical care is frightening and infuriating. Casey Ross and Bob Herman have found that health insurance companies are relying on AI to make crucial decisions about patient care and coverage. One such company, NaviHealth, uses technology called nH Predict to generate algorithmic reports that assess a patient’s mobility and cognitive capacity, and predicts their need for care, their length of stay, and their discharge date. It’s a slick and shiny product, but as Ross and Herman report, it’s an unregulated algorithm “under the guise of scientific rigor” — its “suggestions” leading to the delay or denial of care for patients and ultimately favoring health insurance companies.

Behind the scenes, insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment. The denials that follow are setting off heated disputes between doctors and insurers, often delaying treatment of seriously ill patients who are neither aware of the algorithms, nor able to question their calculations.