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.” 

Related News Articles

Headline
People enrolled in Medicare Advantage are more likely than those in traditional Medicare to report delays in care due to needed insurance approvals, according…
Headline
Andrea Preisler, AHA’s senior associate director of administrative simplification policy, explains why the recent final rule requiring Medicare Advantage,…
Headline
The Centers for Medicare & Medicaid Services yesterday released FAQs clarifying coverage criteria and utilization management requirements for Medicare…
Headline
The Centers for Medicare & Medicaid Services will accept comments through March 1 at 6 p.m. ET on its advance notice of proposed changes to Medicare…
Headline
Chris Barber, president and CEO of St. Bernards Healthcare, discusses the problems certain MA plan practices can create for patients and their caregivers,…
Headline
In a statement submitted to the House Energy and Commerce Subcommittee on Health for a hearing Jan. 31 on national health expenditures, AHA urged the…