Algorithmic claim denial in health insurance

What it is

The same purchased software tool was deployed across competing insurers to decide when elderly patients should stop receiving post-hospital rehabilitation.

Why it matters

The alleged nH Predict reversal rate on appeal is ~90% - but only about 0.2% of denied Medicare Advantage members appeal at all. A tool that loses nine of ten fights, aimed at people who almost never fight. A patient shopping between Medicare Advantage plans could switch brands and land under the identical algorithm.

Companies and rows it touches

UnitedHealthcare and Humana both used nH Predict (built by naviHealth). Cigna's parallel PXDX system allegedly denied 300,000+ claims in two months at ~1.2 seconds average review each.

Where to look

Life-Health-Dental Insurance (UnitedHealthcare, Humana, Cigna rows)