AI Prior Authorization Denial Claims
Class actions target Humana's use of the nH Predict AI tool to automate prior authorization denials for skilled nursing facility care. Plaintiffs allege the tool denies coverage at rates far above what individualized clinical review would support, overriding treating physicians' recommendations.
Medicare Advantage plans must provide at least the coverage traditional Medicare would for the same services. Algorithmic denials ignoring individual patient circumstances arguably violate this equivalence requirement.
Risk Score Fraud Allegations
DOJ whistleblower lawsuits allege Humana systematically inflates Medicare Advantage risk scores -- submitting diagnoses to make patients appear sicker than they are to receive higher government payments. Chart review programs that identify additional diagnoses without ensuring active management are alleged to fraudulently inflate payments.
Who May Have Claims
Medicare Advantage members denied skilled nursing or post-acute care that treating physicians recommended may have appeal rights and civil claims. Whistleblowers with direct knowledge of risk score manipulation may be eligible for qui tam relator shares under the False Claims Act. Related: Veterans Guardian Lawsuit.
Status 2026
DOJ investigation and class action prior authorization claims are both active. No comprehensive settlement has been announced.
How to Get Legal Help
If you believe you qualify based on the eligibility criteria described above, the next step is a free consultation with an experienced attorney. Most plaintiff-side attorneys handling these cases work on contingency -- meaning you pay nothing unless your case results in a recovery. Bring any relevant documentation including receipts, correspondence, or evidence of the harm you experienced. Related: US Money Reserve Lawsuit.
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Humana Lawsuit: Medicare Advantage AI Denials & Risk Score Fraud: Frequently Asked Questions
Answers to the most common questions about this case and your legal options.
Is Humana denying Medicare Advantage claims unfairly?
Lawsuits and CMS investigations allege Humana's AI tool denies claims at rates not supported by clinical review.
Can I appeal a Humana Medicare Advantage denial?
Yes. Federal law provides robust appeal rights. Appeal formally, request expedited review for urgent situations.
Is Humana being investigated for fraud?
Yes. DOJ whistleblower investigations into Medicare Advantage risk adjustment are ongoing.
What is prior authorization?
A requirement that certain services be approved by the insurer before receiving care. Medicare Advantage plans can require prior authorization for some services.
Is there a Humana settlement?
No comprehensive settlement has been announced as of June 2026.