STAT+: How UnitedHealth’s acquisition of a popular Medicare Advantage algorithm sparked internal dissent over denied care
“It was very much about following the algorithms and basically not using your clinical judgment,” one former NaviHealth medical reviewer said. “That was very different from before we were owned…
Frustration was boiling into open conflict within NaviHealth, a company that uses computer predictions to help control the cost of caring for millions of older and disabled Americans on privatized Medicare plans.
The source of the outrage was not a customer or a salesperson, but an algorithm — specifically one that was being used to predict the amount of care needed by seriously ill patients. In 2021, employees raised alarms that efforts to bypass the algorithm — and pay for longer rehab stays — were getting slapped down at higher levels of the organization. Multiple cases involved patients who were still so sick they needed daily infusions to treat infections.
“It’s still happening,” one employee complained in internal communications obtained by STAT. Another added: “I had one that I had to communicate two times that was an IV and very clear on the continued stay — and it was still [denied].”
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