From Health 201AI Med Risk

What happenedIn December 2023 a proposed class action was filed in the US District Court for the Western District of Kentucky alleging that Humana used the nH Predict model, which compares a patient with about six million others to predict how long they will need care, to cut off payment for post-acute rehabilitation for Medicare Advantage members prematurely. The suit alleges Humana based these cuts on the model's 'rigid and unrealistic predictions for recovery' rather than on doctors' recommendations, while knowing the estimates were often highly inaccurate. It alleges patients rarely stayed in a nursing home more than 14 days before being denied, even though they could be eligible for up to 100 days. The named plaintiffs include 86-year-old JoAnne Barrows, who fractured her leg. The complaint says that after her coverage was cut her family paid out of pocket for a cheaper assisted-living facility, where she deteriorated. On 15 August 2025 Judge Rebecca Grady Jennings partly denied Humana's motion to dismiss: claims for breach of contract, breach of the implied covenant of good faith and fair dealing, unjust enrichment and common-law fraud were allowed to proceed, while state statutory unfair-practices and insurance bad-faith claims were dismissed. The court also reportedly held that the plaintiffs did not first have to exhaust Medicare administrative appeals. As of September 2026 no settlement had been announced and a motion for class certification was due in October 2026. The court has not ruled on the merits, and these remain allegations.

Failure modeA population-level length-of-stay prediction was allegedly applied as a hard cutoff for individual coverage, overriding treating clinicians' judgement.

What might have helpedTreating a model's length-of-stay estimate as one input and leaving the decision to clinicians who know the patient could have avoided rigid cutoffs. Independent checks of how often predicted stays matched patients' actual needs, and tracking how many denials were overturned on appeal, could have exposed the inaccuracy the suit alleges.