The lawmakers specifically targeted AI-driven terminations of post-acute care, giving skilled nursing facilities a congressional endorsement for pushing back on coverage decisions made by tools like UnitedHealth’s nH Predict that substitute population statistics for individual patient assessment.
Reps. Jerrold Nadler (NY-12), Judy Chu (CA-28), and Sen. Elizabeth Warren (MA) led 45 House Members and 4 Senators in a bicameral, bipartisan letter this week urging the Centers for Medicare and Medicaid Services (CMS) to increase oversight of artificial intelligence (AI) and algorithmic software tools used to guide coverage decisions in Medicare Advantage (MA) plans. “We remain concerned about MA plans’ use of prior authorization, specifically their ongoing use of artificial intelligence (AI) and algorithmic software to guide coverage decisions. Plans continue to use AI tools to erroneously deny care and contradict provider assessment findings,” wrote the Members to CMS Administrator Chiquita Brooks-LaSure. Several MA insurers are using unregulated algorithms and AI tools to determine when to cut off payment for patient treatments, leaving vulnerable seniors—who have spent their lives paying into Medicare—left to either pay for their care themselves or go without it.
Office of Congressman Jerrold Nadler, June 25, 2024
Lawmakers say CMS should ban Medicare Advantage’s use of AI to deny care
The Centers for Medicare & Medicaid Services should consider banning artificial intelligence from being used to deny Medicare Advantage coverage pending a “systematic review,” a group of 49 congressional leaders is urging. The group, led by Sen. Elizabeth Warren (D-MA) and Reps. Jerry Nadler (D-NY) and Judy Chu (D-CA), sent a joint letter to the regulator agency Tuesday, detailing their concerns and suggestions regarding the use of AI for informing or determining coverage denials for Medicare Advantage patients. Skilled nursing providers have been sounding the alarm for years on Medicare Advantage coverage access, especially when informed by AI and other algorithms.
McKnight’s Senior Living, June 28, 2024
The lawmakers highlighted instances where AI-driven tools allegedly led to denials of care, contradicting assessments made by health care providers, and noted a lawsuit filed against UnitedHealth Group for pressuring employees to use such tools in care denial.
Skilled Nursing News, June 26, 2024
Stop letting MA plans deny care using AI tools, lawmakers urge CMS
In a letter sent Tuesday, the lawmakers cited a STAT investigation in calling on the Centers for Medicare and Medicaid Services to beef up oversight of AI and algorithmic tools that discriminate against old and sick patients. “These tools apply a generalized need for care to an individual beneficiary’s situation, resulting in generalizations instead of person-centered approaches to care, which is antithetical to the mission of the Medicare program,” the lawmakers wrote.
STAT, June 25, 2024
Lawmakers seek tougher AI restrictions for Medicare Advantage
A bipartisan group of senators and U.S. representatives is putting pressure on the Biden administration to get tougher on Medicare Advantage carriers’ use of artificial intelligence and related technologies.
Modern Healthcare, June 25, 2024
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