SAN FRANCISCO — When Megan Bent and her mother won the last appeal against UnitedHealth’s denial of care for her father, she remembered the reason given: it was unsafe for him to come home. Bent’s father had been recovering at a rehabilitation facility after brain surgery to remove a melanoma metastasis. Three days later, his condition hadn’t changed, but Bent and her family received another denial of care. It was their third denial and, this time, they lost.
These denials came after NaviHealth, a company that uses an algorithm to estimate a patient’s care needs and was doing so for UnitedHealth, told the family he only needed a couple weeks to recover. That flew in the face of what the neurosurgeon and physical therapist told the family. The medical team expected Bent’s father would need at least three months in the facility, Bent recalled.
“We’d never heard of NaviHealth before,” Bent said, speaking at the STAT Breakthrough Summit in San Francisco. “My mom said they hadn’t developed a care plan yet, and the physical therapist thinks he needs to be there in three months. The other woman laughed and said, ‘oh, those physical therapists, they think they can fix everything.’”
A STAT investigation showed that UnitedHealth, which acquired NaviHealth in 2020, and other Medicare Advantage insurers have been using this algorithm to predict how long patients would need to stay in certain medical facilities, and cut off coverage beyond that calculated length of stay. UnitedHealth phased out the NaviHealth brand in 2024, but the use of these algorithms continues, said Christine Huberty, an attorney at the Center for Medicare Advocacy and who also spoke at the STAT summit in San Francisco.
In a statement read by STAT senior writer Matthew Herper before the discussion, UnitedHealth accused STAT of seeking “to profit off anecdotal and unproven statements.” The statement said that “any allegation that UnitedHealthcare uses an AI algorithm to automatically deny claims is false. We do not employ AI to issue any adverse clinical determinations. We have shared these facts, along with extensive supporting data, and STAT has engaged in multiple conversations with our top clinicians, but STAT continues to ignore the truth and perpetuate an inaccurate and pre-determined narrative around AI to scare people and create click-bait headlines.”
STAT’s investigation, by reporters Casey Ross and Bob Herman, was a finalist for a Pulitzer Prize, and UnitedHealth has never agreed to put any representative on the record to answer questions. Huberty and Bent both spoke on the record on STAT’s stage in San Francisco, discussing their experiences with UnitedHealth and other insurers that employed the NaviHealth algorithm.
Bent’s father, Gary Bent, was a physics teacher. He worked as an assistant head of the University of Connecticut’s physics department before retiring and teaching high school. An obituary from UConn’s physics department described him as a dedicated educator who would sometimes dress as a wizard while performing physics demonstrations for his students. “My dad was a great father,” Bent said. “He would come up with really fun ways to share theories of physics with his students, and received letters for years and years afterwards about how he developed their love of science.”
He’d been in remission from advanced melanoma until, Bent said, one day, he woke up and couldn’t remember how to tie his shoes — an effect from the metastatic bleeding lesion in his brain. After the neurosurgeon removed the tumor, Gary Bent was in bad shape. “He couldn’t walk. He had left neglect, where his body couldn’t recognize it had a left side. He couldn’t remember how to do things like use the telephone,” Bent said. The care team estimated he would need months in an acute rehab facility, though United refused to cover that stay and would only cover care in a skilled nursing facility instead.
That’s why the phone call from NaviHealth made so little sense and, for Bent’s family, was making a difficult situation worse. “Someone on the phone was saying he has to be discharged in two weeks, and now we had to figure out — is he going to come home? If he does, we have to move because it needs to be a wheelchair accessible apartment,” Bent said. “You’re already in crisis, and this care is going to end. You have to figure out what you’re going to do.”
People at the nursing facility told her they were familiar with the drill. After two weeks, there’d be a denial of care. If you appeal and win, they send another one, usually three or four days later. Bent and her mother won the first two appeals. After the third, Gary Bent came home with a bacterial meningitis infection and had to be rushed to the hospital hours later. “Before that infection, he was getting to the point where we thought he was going to be strong enough to go back into immunotherapy for his cancer,” Bent said. “He was never able to regain that strength. We took care of him until he passed away in March of 2023.”
Center for Medicare Advocacy’s Huberty said she used to hear stories of denials similar to Bent’s once or twice per week when she was working at a nonprofit in Wisconsin serving seniors. “2022 was probably the height of it. It was always Medicare Advantage plans,” she recalled. A Senate investigation found that insurers including UnitedHealth had used technology to ramp up denial of claims, and the congressional report found that as of 2022 UnitedHealth, Humana, and CVS Health had denied about a quarter of claims for post-acute care among Medicare Advantage members. Both Huberty and Bent testified before the congressional committee for that investigation. (The Department of Justice has also begun a separate probe into possible criminal Medicare Advantage fraud from UnitedHealth.)
The Centers for Medicare and Medicaid Services is the regulatory body for denials of claims, Huberty said. And the agency “has tried to put out things, proposed rules, guard rails, asking for more transparency about the use of AI. UHC will sidestep and say, well it’s not AI. You don’t have to regulate us if we call it not AI,” Huberty said. “But everyone is highly directed by the AI tool. Even if the medical directors are the ones making the denials, the denial process has been started by the tool.”
Recently, Huberty said she hasn’t seen the NaviHealth name or the NH predict tool mentioned. “It is just not there,” she said, but these denials triggered by AI continue to happen. “I see the same pattern of denials. You get a week or two, then denials every three to four days. Same frequency, across the board.”
Regulation has to be part of the solution, Bent said. “Meeting you, Christine, and your powerful investigating,” she said, turning to Ross, who moderated the session. “It helped me understand that this is happening to so many people, and that’s so deeply troubling as well. What we went through as a family, we’re just one story among thousands.”
