People Over Profit- Lokken v UnitedHealth

Gene Lokken

Gene Lokken's family are lead plaintiffs in a lawsuit against UnitedHealth.

After Lokken fractured his leg, UnitedHealth covered only 19 days of therapy, stunning his doctors and therapists, who described his muscle functions as “paralyzed and weak.”

The family appealed the denial, but was rejected.

Dale Tetzloff

Dale Tetzloff needed 100 days of post-acute care after a stroke. But, after just 20 days, UnitedHealth denied further coverage.

His family appealed the denial, but ultimately wound up paying $70,000 out of pocket for his care.

Jackie Martin

Jackie Martin was getting rehab at a nursing home after a back fracture when UnitedHealth terminated his coverage. He appealed, but was sent multiple coverage termination letters.

He returned home. Five days after UnitedHealth cut off his nursing home coverage, he died alone in his bathroom.

A CLASS ACTION LAWSUIT WITH NATIONWIDE RAMIFICATIONS

In November 2023, the family of Gene Lokken and several other Medicare Advantage beneficiaries filed a class action against UnitedHealth Group. Though still early in the litigation process, the case could have significant ramifications for the American healthcare system.

Through the Medicare Advantage program, insurers like UnitedHealth are paid a lump sum to cover services for patients. The more insurers deny care, the more taxpayer dollars remain in the insurance company’s pockets.

This has had predictable results as insurers seek to maximize profits at the cost of patient care. According to an investigation by the U.S. Senate permanent subcommittee on investigations, UnitedHealth’s prior authorization denial rate for post-acute care for older people on Medicare Advantage shot up from 8.7% to 22.7% in a three year period. For Medicare Advantage seniors seeking post-acute care in nursing homes specifically, UnitedHealth’s denial rate jumped up dramatically, from 1.4% to 12.6%.

In actual numbers, this amounts to tens of thousands of denials to vulnerable elderly patients.

BATTLING AN AI ALGORITHM WITH A 90% ERROR RATE

The Lokken V UnitedHealth lawsuit alleges that UnitedHealth illegally uses an algorithm to deny care, despite the algorithm having a high error rate. The lawsuit claims that United Health intentionally employs the algorithm with its high rate of denial knowing only a small percentage of patients will file appeals. The algorithm, nH Predict, has a 90% error rate, based on the percentage of payment denials reversed through internal appeals processes.

According to the lawsuit, UnitedHealth started using nH Predict in November 2019, and it is still in use. The algorithm estimates medical needs, length of stay, and discharge date for patients. But according to a Stat investigation, the estimates are often severely limiting. For instance, on a Medicare Advantage Plan, patients who stay in a hospital for three days are usually entitled to up to 100 days of covered care in a nursing home. But the nH Predict algorithm rarely allows more than 14 days before patients begin receiving denials from UnitedHealth.

THE TRAGIC HUMAN IMPACT

When Jackie Martin's coverage was terminated by UnitedHealth, he was getting rehab at a nursing home for a back fracture. He appealed, but UnitedHealth continued sending multiple coverage termination letters. Finally, exhausted by the back-and-forth and frustrated at his inability to get coverage, Jackie returned home.

At this point in his recovery, he could not walk more than five steps without being out of breath. And five days after UnitedHealth cut off his nursing home coverage, he died alone in his bathroom.

Jackie's family are among the plaintiffs in the ongoing class action against UnitedHealth. Read more about the stories of Jackie Martin, Gene Lokken, and Dale Tetzloff at the links above.