Dive Transient:
- A distinguished Democrat lawmaker is questioning main Medicare Benefit insurers about their use of synthetic intelligence to make care selections.
- In letters despatched to CVS Well being, UnitedHealthcare and Humana on Thursday, Sen. Richard Blumenthal, D-Conn., pressed the payers on whether or not they make protection selections primarily based on AI instruments or predictive know-how, which merchandise are in use and whether or not they have applied any guardrails to forestall the instruments from influencing suppliers’ work.
- The letter comes a yr after the Senate Everlasting Subcommittee on Investigations, the place Blumenthal is rating member, launched a report criticizing the insurers for utilizing predictive know-how to disclaim claims for post-acute care.
Dive Perception:
Insurers’ rising use of AI in protection selections has confronted scrutiny from some lawmakers involved that the know-how might deny care unfairly, particularly within the MA program. UnitedHealth and Humana have already confronted class motion lawsuits over their use of predictive know-how in protection determinations.
Final yr’s report from the Senate Everlasting Subcommittee on Investigations discovered the variety of prior authorization requests or denial charges for post-acute care elevated on the three main MA payers as they invested in predictive applied sciences. Now, Blumenthal is following up on the evaluation. Because the report’s publication, the fast growth of AI in healthcare has “solely elevated the potential of its abuse,” he wrote within the letter.
For instance, an evaluation printed final yr by the American Hospital Affiliation discovered care denials in business and MA plans elevated from 2022 to 2023, partially due to the elevated use of AI instruments.
And regulators and the general public have restricted info on insurers’ protection denials and the position AI performs, Blumenthal wrote.
“Consequently, the American individuals proceed to be reliant on little greater than insurers’ guarantees that they don’t seem to be taking potential life-and-death selections away from medical doctors and giving them to machines,” he stated.
AI is more and more being applied by payers to deal with duties like prior authorization, the place suppliers should receive approval earlier than providing sure providers or medicines.
Proponents say the know-how might scale back administrative work and pace prior authorization requests, a course of that’s regularly criticized by suppliers for taking an excessive amount of time and delaying obligatory care.
In the meantime, federal oversight of AI in healthcare is comparatively nascent, and the Trump administration plans to pursue a deregulatory agenda to spur growth of the know-how within the U.S.
The CMS has additionally moved to make use of AI in conventional Medicare. Beneath the Wasteful and Inappropriate Service Discount, or WISeR, pilot program, medical doctors in a choose group of states will probably be required to safe AI-backed prior authorization for some providers.
A CVS spokesperson instructed Healthcare Dive the corporate had acquired the letter and can reply. UnitedHealth and Humana didn’t reply to requests for touch upon the letter by press time.
