HEARTLESS PLAN –

May 22, 2024 – Investigations found those payment denials were based on an algorithm’s predictions, unbeknownst to patients, and UnitedHealth’s employees were advised not to stray from those calculations — forcing extremely sick and injured patients to pay for care out of their own pockets or return home even if they couldn’t walk or go to the bathroom independently. As the class action case has ramped up, a flurry of changes have unfolded at NaviHealth, the company that monitors care and implements the algorithm. Its longtime CEO, Harrison Frist, the son of former Senate Majority leader Bill Frist — who helped write Medicare Advantage into law — recently resigned. A round of layoffs also swept through the company, and UnitedHealth has scrubbed NaviHealth’s brand off its ledger, even as it continues to use its computer model to help decide how much rehab care patients should receive.

Medicare has a multi-step process for Medicare Advantage enrollees to appeal payment denials. If they lose after first appealing to the health insurance company, they then go to an independent contractor called a quality improvement organization. If appeals fail there twice, patients can next appeal to an administrative law judge. The final stop is the Medicare Appeals Council.

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