Medicare Advantage cannot rely exclusively on AI to deny coverage

For some time now, UnitedHealth and other health insurance companies are reported to have been using artificial intelligence tools to broadly deny coverage in certain instances for people enrolled in Medicare Advantage plans. Insurers claim that the tools simply help them determine whether to deny a service. Use of these tools appears to have led to large numbers of inappropriate denials of care for Medicare Advantage enrollees, and the Biden administration is now stepping in reports SkilledNursingNews.

The Centers for Medicare & Medicaid Services (CMS), which oversees Medicare, is restricting insurers’ ability to use AI tools to deny claims for Medicare Advantage enrollees. It issued an FAQ to insurers offering Medicare Advantage plans to ensure insurers understand that Medicare Advantage plans cannot deny care without considering individual patient’s needs.

The FAQ explains how insurers can use algorithms and AI in Medicare Advantage. And, it clarifies coverage requirements for post-acute care to help ensure patients aren’t wrongly denied critical care. Insurers can use prior authorization, but not in an emergency or urgently needed care situations or for out-of-network services they cover.

While insurers can use AI in determining whether to cover a service, they are responsible for making sure that the AI complies with the Medicare coverage rules. And, they can’t rely exclusively on AI. Insurers offering MA must consider each individual enrollee’s situation, including the enrollee’s medical history and treating physician’s recommendation, in deciding whether care is medically necessary. And, before an insurer ends services for MA enrollees, their individual conditions must be reevaluated.

Furthermore, insurers must publicly release their coverage criteria on a website and cannot change it as they please, according to CMS. And, if your doctor says you need post-acute care in a rehab facility, your health insurer cannot second-guess that decision so long as you meet Medicare coverage criteria for such care.

If an insurer still denies coverage, it bears the burden of proof on appeal that care is not medically necessary through a detailed explanation. And, a provider with expertise in that care must issue the denial.

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