Democratic Lawmakers Call for CMS to Restrict Use of AI for Prior Authorization
Summary
A group of Democratic Members of the House of Representatives is urging the Centers for Medicare & Medicaid Services (CMS) to increase its guardrails around the use of AI for prior authorization by Medicare Advantage (MA) plans. MA plans may currently use AI to assist in coverage determinations in certain care settings, such as inpatient hospital, skilled nursing facilities and home health. The letter points to a report from the HHS Office of Inspector General (OIG), which reported high numbers of inappropriate denials, linked to use of AI. The letter pressures CMS to adopt a list of measures, such as requiring MA plans to justify denials, assess the frequency of denials, determine the extent to which AI contributed to the denial decision, whether algorithms are self-correcting (i.e., if the denial is reversed on appeal, whether that would be factored into the algorithm) and whether plans are inappropriately using race or other factors in algorithms.
