Today, Reps. Jerrold Nadler (NY-12) and Judy Chu (CA-28) led 30 of their colleagues in sending a letter to Administrator Chiquita Brooks-LaSure of the Centers for Medicare and Medicaid Services (CMS) to urge increased oversight of artificial intelligence (AI) and algorithmic software tools used to guide coverage decisions in Medicare Advantage (MA) plans.
“In recent years, problems posed by prior authorization have been exacerbated by MA plans’ increasing use of AI or algorithmic software to assist in their coverage determinations in certain care settings, including inpatient hospital, skilled nursing facilities, and home health. Advocates and the media report that the use of such software has led to coverage decisions that are more restrictive than allowed under traditional Medicare rules, as well as more frequent and repeated denials of care,” wrote the Members. “Absent prohibiting the use of AI/algorithmic tools outright, it is unclear how CMS is monitoring and evaluating MA plans’ use of such tools in order ensure that plans comply with Medicare’s rules and do not inappropriately create barriers to care.”
To ensure proper oversight of MA plans, the Members call on CMS to require MA plans to: report prior authorization data including reason for denial, by type of service, beneficiary characteristics (such as health conditions) and timeliness of prior authorization decisions; compare “guidance” generated by these tools with actual MA coverage decisions; and assess the data that plans are relying on to make these determinations and whether plans are inappropriately using race/other factors in these algorithms, among other measures.
“Medicare Advantage plans are entrusted with providing medically necessary care to their enrollees,” the Members concluded. “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.”
This letter is endorsed by: the Center for Medicare Advocacy, Public Citizen, Social Security Works, Center for Health and Democracy, and Business Leaders for Health Care Transformation.
“The use of AI by Medicare Advantage insurers to deny needed care to seniors and people with disabilities represents the most recent and dangerous step by greedy companies focused on profit instead of patients. Now is the time for CMS to crack down on companies that are using AI and other mechanisms to deny care that would be covered if the enrollee were covered by Traditional Medicare. Understanding how Medicare Advantage insurers are using AI to deny needed care and holding bad actors accountable are crucial steps to protecting seniors and the Medicare program,” said Lisa Gilbert, Executive Vice President at Public Citizen.
“In our experience, when Medicare Advantage plans use algorithmic software to determine what services the plan will cover, more care is denied or prematurely terminated in a manner that is more restrictive than allowed under Medicare rules. Absent banning the use of such tools, CMS must step up oversight to ensure that MA enrollees are getting the care they need,” said David Lipschutz, Associate Director/Senior Policy Attorney at Center for Medicare Advocacy.
Reps. Chu and Nadler were joined by Representatives: Barbara Lee (CA-12), David Trone (MD-06), Nikki Budzinski (IL-13), Katie Porter (CA-47), Lloyd Doggett (TX-37), Shri Thanedar (MI-13), Chellie Pingree (ME-01), Ted Lieu (CA-36), Pramila Jayapal (WA-07), Sheila Cherfilus-McCormick (FL-20), Nydia M. Velázquez (NY-07), Henry C. “Hank” Johnson, Jr. (GA-04), Mark Takano (CA-39), Mark Pocan (WI-02), Rosa DeLauro (CT-03), Grace Napolitano (CA-31), Dan Goldman (NY-10), Ayanna Pressley (MA-07), André Carson (IN-07), Raúl M. Grijalva (AZ-07), Adriano Espaillat (NY-13), James P. McGovern (MA-02), Paul D. Tonko (NY-20), Sean Casten (IL-06), Bonnie Watson Coleman (NJ-12), Sylvia Garcia (TX-29), Al Green (TX-09), Jamaal Bowman (NY-16), and Dwight Evans (PA-03).
Click here for the full text of the letter.
U.S. Representative Jerrold Nadler represents New York's 12th Congressional District, which includes parts of Manhattan, and serves as the Ranking Member of the House Judiciary Committee.