Lawmakers are pushing CMS to do more to prevent misuse of artificial intelligence by Medicare Advantage plans.
A group of 51 lawmakers signed a letter to CMS Administrator Chiquita Brooks-LaSure on June 25, asking the agency to implement more stringent oversight regarding the technology.
In November, families of two UnitedHealthcare Medicare Advantage members sued the company, alleging naviHealth, an AI algorithm, wrongfully denied the men post-acute care. An Optum spokesperson previously told Becker's the product is not used to make coverage determinations.
"We remain concerned about MA plans' use of prior authorization, specifically their ongoing use of artificial intelligence algorithmic software to guide coverage decisions," the lawmakers wrote. "Plans continue to use AI tools to erroneously deny care and contradict provider assessment findings."
In February, CMS published guidance on how artificial intelligence can be used by MA plans. In its guidance, the agency said payers can use algorithms to support coverage decisions, but it is their responsibility to ensure that an algorithm or an AI-based tool is compliant with CMS requirements.
MA plans can use algorithms only to help predict length of stay for post-acute services and not as the basis for terminating coverage, CMS said in February.
At a February hearing, experts told members of the Senate Finance Committee that CMS' guidance may not be clear enough to prevent misuse of AI.
In the letter, lawmakers urged CMS to implement more specific guidance around how plans can use AI. The legislators asked the agency to create an approval process to vet new AI tools used by insurers, and to prohibit the use of AI tools in coverage decisions until the agency has completed a systematic review.
"We believe more detailed guidance is needed to protect access to care for Medicare beneficiaries and improve clarity for providers," the lawmakers wrote.
Read the full letter here.