Lawmakers probe Medicare Advantage plans' use of AI

A group of federal lawmakers is asking CMS to increase its oversight of artificial intelligence and algorithms used in Medicare Advantage prior authorization decisions. 

Thirty U.S. representatives wrote to CMS Administrator Chiquita Brooks-LaSure on Nov. 3, asking the agency to require MA plans to report prior authorization data, including reasons for denials. 

The lawmakers also asked the agency to:  

  • Compare guidance generated by AI tools to actual Medicare Advantage coverage decisions. 
  • Assess if AI-powered algorithms used in prior authorization are self-correcting.
  • Require plans to attest that their prior authorization requirements are not more restrictive than traditional Medicare. 

A 2022 report from HHS' Office of Inspector General found 13% of prior authorization denials in Medicare Advantage would have been approved in traditional Medicare. 

In their letter, lawmakers pointed to advocacy group reports that indicate use of AI in Medicare Advantage prior authorization decisions is resulting in care denials that are more restrictive than is allowed in traditional Medicare. 

Read the full letter here.

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