House letter on AI use in Medicare Advantage denials

Over 30 members of the House of Representatives Nov. 3 urged the Centers for Medicare & Medicaid Services to monitor and evaluate how Medicare Advantage plans use artificial intelligence and algorithms to guide their coverage decisions, and ensure these tools comply with Medicare rules and do not create barriers to care. Among specific actions, they urged CMS to require MA plans to report prior authorization data (including the reason for denial) by type of service, beneficiary characteristics and timeliness of prior authorization decisions, and attest that their coverage guidelines are not more restrictive than traditional Medicare. The House members also urged CMS to compare “guidance” generated by these tools with actual MA coverage decisions, and assess the data used to make coverage determinations and whether the AI/algorithms self-correct when a plan denial or premature termination of services is reversed on appeal.
 
“Medicare Advantage plans are entrusted with providing medically necessary care to their enrollees,” they wrote. “While CMS has recently made considerable strides in ensuring that this happens, more work is needed with respect to reining in inappropriate use of prior authorization by MA plans, particularly when using AI/algorithmic software.”