Lawmakers ask CMS for greater oversight of MA coverage decisions
"Plans continue to use AI tools to erroneously deny care and contradict provider assessment findings," lawmakers say.
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A bipartisan group of lawmakers is asking the Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure for greater oversight of Medicare Advantage coverage decisions.
Over 50 House Representatives and Senators sent a letter on June 25 to Brooks-LaSure saying they are concerned about MA plans' use of prior authorization, specifically the ongoing use of artificial intelligence and algorithmic software by insurers to guide coverage decisions.
"Plans continue to use AI tools to erroneously deny care and contradict provider assessment findings," the lawmakers said.
WHY THIS MATTERS
The lawmakers cited a class action lawsuit brought against UnitedHealth Group last year for allegedly unlawfully using an AI algorithm, nH Predict, to deny rehabilitative care to Medicare Advantage patients.
"The lawsuit cites an investigation suggesting that UnitedHealth Group pressured employees to use the algorithm to issue payment denials to Medicare Advantage beneficiaries and set a goal for employees to keep patient rehabilitation stays within 1% of the length of stay predicted by nH Predict," the letter said. "We believe more detailed guidance is needed to protect access to care for Medicare beneficiaries and improve clarity for providers."
The lawmakers urged CMS to ask MA plans for more detailed information about denials. They reiterated a request sent in a November 2023 letter that MA plans report the reason for the denial, the type of service, beneficiary characteristics (such as health conditions) and the timeliness of prior authorization decisions.
"Clarify the specific elements that must be contained in denial notices," the letter said.
THE LARGER TREND
Lawmakers said CMS has increased consumer protections in the Medicare Advantage program, particularly with respect to prior authorization, in the final Part C and D Interoperability and Prior Authorization Final Rule and in the 2025 Medicare Advantage and Part D Final Rule.
Email the writer: SMorse@himss.org
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