The OIG needs to look very carefully at these devastating practices and not just give MA plans who don't follow Medicare standards more than a slap on the wrist!
According to the lawsuit, UnitedHealth started using nH Predict in at least November 2019, and it is still in use. The algorithm estimates how much post-acute care a patient on a Medicare Advantage Plan will need after an acute injury, illness, or event, like a fall or a stroke. Post-acute care can include things like therapy and skilled care from home health agencies, skilled nursing homes, and inpatient rehabilitation centers. It's unclear how nH Predict works exactly, but it reportedly estimates post-acute care by pulling information from a database containing medical cases from 6 million patients. NaviHealth case managers plug in certain information about a given patient—including age, living situation, and physical functions—and the AI algorithm spits out estimates based on similar patients in the database. The algorithm estimates medical needs, length of stay, and discharge date. According to the Stat investigation and the lawsuit, the estimates are often draconian. For instance, on a Medicare Advantage Plan, patients who stay in a hospital for three days are typically entitled to up to 100 days of covered care in a nursing home. But with nH Predict, patients rarely stay in nursing homes for more than 14 days before receiving payment denials from UnitedHealth.
