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Congress Questions AI’s Role in Medicare Advantage Denials

Policymakers are asking the Biden Administration to investigate artificial intelligence’s role in decisions about which seniors get medical care.

Thirty House Democrats sent a letter to the Centers for Medicare and Medicaid Services asking for oversight of the use of algorithms to process coverage claims. The letter referenced “widespread and persistent problems related to denials of care and payment in Medicare Advantage” plans, which could be made worse by overreliance on AI.

AI May Increase Claims Errors

A 2022 study estimated that 13% of prior authorization requests denied by more restrictive Medicare Advantage plans were for services actually covered by Medicare. In short, wrongful denials already impact millions of patients, even with humans calling the shots.

When proprietary algorithms and AI are used to initiate claim denials, seniors may have still more barriers to access. Unlike humans, AI may not take individual patient circumstances into account. Auto-generated denials only make it easier to bury patients in paperwork, forcing them to pay high out-of-pocket costs while navigating a lengthy appeals process.

No clinician — in fact, no human — will even see the patient’s information and compare it against the coverage contract. As a result, coverage is likely to be more restrictive under AI claims screening processes. This could be devastating to patients, particularly those living with headache and migraine.  

Headache and migraine can be challenging – sometimes debilitating. Not only physically difficult, these conditions can also come with a host of other symptoms, from anxiety and depression to social isolation. People who live with them can’t just simply tolerate things while they try to navigate a more confusing insurance environment thanks to AI.  

Lawmakers, Advocates Look for More Oversight

The House letter suggests requiring Medicare Advantage plans to certify that AI-processed care is not more restrictive or burdensome for patients, and to provide some tools for pushing back if more patients are denied. The Centers for Medicare and Medicaid Services itself has proposed some rules around prior authorization, including reducing the wait time for decisions.

Patient advocates have also raised alarms that allowing Medicare Advantage plans to use AI screening with minimal public oversight sets a dangerous precedent for private insurers to do the same, resulting in an overall tightening of coverage and patient eligibility.

As Rep. Jerrold Nadler (D-NY), who signed onto the House letter to the Centers for Medicare and Medicaid Services, wrote on X, “Patients should be able to trust that their insurer will work with doctors, not computers, to make coverage decisions for necessary care.”

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