UnitedHealth’s Optum working on Medicare Advantage AI risk score system

Bob Herman covers health insurance, government programs, hospitals, physicians, and other providers — reporting on how money influences those businesses and shapes what we all pay for care. He is also the author of the Health Care Inc. newsletter. You can reach Bob on Signal at bobjherman.09.

SAN DIEGO — Optum, the health data and care provider division of UnitedHealth Group, is developing a way to calculate how sick Medicare patients are through artificial intelligence, instead of relying solely on diagnosis codes submitted by physicians.

Ken Cohen, a physician and Optum’s executive director of translational research, said Thursday at a conference organized by America’s Physician Groups that he was working with the Duke-Margolis Institute for Health Policy on this “next generation” of Medicare risk coding using AI.

UnitedHealth and Optum have a significant interest — both reputationally and financially — in helping to build a new type of coding system. The broader company is facing a criminal fraud investigation by the Department of Justice related to Medicare Advantage, the Wall Street Journal reported this week. That comes on top of a civil investigation over its billing and coding, as well as an antitrust investigation.