Plaintiffs Reject Humana’s Medicare Claims Seeking To Dismiss Lawsuit Over AI

July 9, 2024 1:28 pm

Class-action plaintiffs are asking a federal district court to reject arguments by healthcare insurance giant Humana that the Medicare Act’s administrative appeals process should block litigation over its use of artificial intelligence to process coverage claims.

“Humana argues this Court lacks jurisdiction over Plaintiffs’ claims, asserting that Plaintiffs’ claims arise under the Medicare Act, which requires them to exhaust administrative remedies,” the plaintiffs tell the U.S. district court for western Kentucky in their June 27 opposition to the company’s motion for dismissal of the case.

“Humana is wrong and overstates the jurisdictional nature of the exhaustion analysis,” the plaintiffs argue, saying the Medicare appeals process should be waived because plaintiffs face “irreparable” harm while awaiting the outcome of what can be a lengthy process overseen by the secretary of Health and Human Services.

According to the filing, “Humana’s conduct puts Plaintiffs at risk of irreparable harm if they were required to exhaust administrative remedies” and “exhaustion would be futile because Humana abuses the appeals process and the Secretary lacks the authority to grant the relief sought by Plaintiffs via administrative appeal.”

The plaintiffs’ request for the court to reject Humana’s motion for dismissal filed June 6 is the latest development in a high-profile case that could have impacts for the entire healthcare sector by setting new legal standards for the use of AI by insurance providers.

“This putative class action arises from Humana’s unlawful and undisclosed use of artificial intelligence to wrongfully make coverage determinations for elderly patients’ post-acute care without sufficient individualized review by doctors,” says the plaintiffs’ opposition to the motion for dismissal.

“Humana uses an AI Model known as nH Predict to make claims determinations and override real treating physicians’ determinations as to medically necessary care patients require,” the plaintiffs allege, saying the company knows the AI model’s results “are highly inaccurate and are not based on patients’ individual medical needs but continues to use nH Predict to make coverage determinations to the detriment of its insureds.”

Humana last month asked the court to “seal” its response to an amended complaint claiming the Health Insurance Portability and Accountability Act requires protecting sensitive information contained in the response.

Humana “simply asks this Court to allow the redacted portions of both documents (along with the unredacted versions of those documents) to remain permanently under seal,” the company said in its June 6 motion for a sealed submission to the complaint.

The revised complaint was filed after the court and parties in the case agreed that plaintiffs would submit an amended lawsuit on April 22 after Humana filed a motion for dismissal of the initial complaint.

The plaintiffs’ latest filing is in response to Humana’s motion last month for dismissal of the case.

“Now, Humana brings their Motion to Dismiss (‘MTD’) arguing that Plaintiffs’ claims should be dismissed because: (1) this Court lacks jurisdiction because Plaintiffs were required to exhaust administrative remedies and failed to do so; and (2) that Plaintiffs’ claims are preempted by the Medicare Act,” says the latest filing by plaintiffs. “Both arguments fail,” they tell the court.