Humana's most severe legal and ethical controversies involve systemic denial of patient care using flawed predictive algorithms and major Medicare fraud settlements. Critics and lawsuits target its utilization of automated tools to prematurely cut off necessary rehabilitation and nursing care for elderly patients, alongside multi-million dollar federal fraud recoveries.
Systematic Care Denials via Algorithms
- The nH Predict Tool: Humana faced major class-action lawsuits for using an algorithmic model called nH Predict (developed by NaviHealth) to systematically forecast and cut off coverage for post-acute rehabilitation and skilled nursing facility care.
- Impact on Patients: Lawsuits allege the algorithm superseded individual doctor evaluations, leading to wrongful, repetitive denials of medically necessary care for vulnerable seniors who were forced to pay out-of-pocket or forego treatment.
Medicare and Billing Fraud Settlements
- Part D Bid Fraud ($90 Million Settlement): Humana paid $90 million to resolve a landmark whistleblower lawsuit brought by a former actuary. The suit accused Humana of keeping two sets of books and submitting fraudulent, inflated bids to the Centers for Medicare & Medicaid Services (CMS) for prescription dr-g contracts from 2011 to 2017.
- Overcharging Federal Audits: Federal audits by the Office of Inspector General (OIG) have repeatedly caught Humana overcharging Medicare by tens to hundreds of millions of dollars through unsupported risk-adjustment diagnoses.