HJBR Jan/Feb 2026

FIGHTING FOR CARE 12 JAN / FEB 2026 I  HEALTHCARE JOURNAL OF BATON ROUGE   Clarke called for a supplemental hearing, which took place on Jan. 17, 2024. On the first day of February, he issued a decision “fully favorable to the appellant,” 7 put- ting Humana on the hook for the first two months of respite care Mom paid for at the SNF. Maximus told Humana they must pro- vide notice within 60 days showing that the insurer had paid for the services, per Judge Clarke’s decision. Sixty days later, Humana had not made payment. The process of fighting to get what was due began on April 12, not long after Mom was back to living alone at her condo. Edie and I called OMHA in hopes of receiving guidance on the matter. When we asked if there was any means of enforce- ment to ensure companies like Humana actually obey such decisions, we learned there is no official administrative check to ensure giant corporations don’t flout a fed- eral judge’s ruling. Katrice at OMHAsaid she wished she could do more to help us. Mom would not see what she eventually deemed her “Easter Bunny”until the end of June 2024, nearly five months after the deci- sion. And that only happened after innumer- able phone calls, including a couple to the office of our U.S. senator, Bill Cassidy, MD. Not an Exception, but a Pattern It was Katrice who told us about the class-action lawsuits filed against Humana and UnitedHealth. She mentioned them around the time of our first hearing with Judge Clarke. The lawsuit claims track with everything we learned along the way. Additionally, award-winning reporting by STAT News would demystify for us Huma- na’s infuriating gaslighting by revealing the shocking truth behind their decisions. Casey Ross and Bob Herman of STAT News led their four-part investigation (which became a Pulitzer Prize finalist) in March 2023 with a bombshell report, “Denied by AI: How Medicare Advantage Plans Use Algorithms to Cut Off Care for Seniors in Need.” 8 While health insurers have denied claims “as long as they’ve been around,”Ross and Herman uncovered how “artificial intelligence is now driving their denials to new heights in Medicare Advan- tage.”Their reporting explains, “Behind the scenes, insurers are using unregulated pre- dictive algorithms, under the guise of scien- tific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment.” Seniors who paid into Medicare for decades, “and are now facing amputation, fast-spreading cancers, and other devastat- ing diagnoses, are left to either pay for their care themselves or get by without it. If they disagree, they can file an appeal, and spend months trying to recover their costs, even if they don’t recover from their illnesses.” As the chief operating officer of a palliative and hospice facility lamented in the article, often “the appeal outlasts the beneficiary.” On the same day we learned of the law- suits, I began writing InHumana:AnAmeri- can Healthcare Story , about a subject I was ignorant of just a few months earlier. In researching Medicare Advantage plans, I soon learned many of the major insurers use some sort of unregulated AI to “man- age” how much post-acute care a member receives. 9 The STAT investigation also revealed that Humana isn’t the only insurer to use mushy Medicare rules in an attempt to justify unjust denials. “A recent examina- tion by federal inspectors of denials made in 2019 found that private insurers repeat- edly strayed beyond Medicare’s detailed set of rules. Instead, they were using internally developed criteria to delay or deny care,” wrote Ross and Herman. “In researching Medicare Advantage plans, I soon learned many of the major insurers use some sort of unregulated AI to “manage” how much post- acute care a member receives.”