The Centers for Medicare & Medicaid Services (CMS) issued a directive to Medicare Advantage insurers, emphasizing that AI or algorithms must not be used to deny health care coverage, ensuring decisions are based on individual patient circumstances.
Key Points
- CMS sent a memo to Medicare Advantage insurers, clarifying that health care coverage decisions must prioritize the individual patient’s needs over algorithmic predictions.
- Recent lawsuits against UnitedHealth and Humana highlighted the misuse of AI tools, like nH Predict, leading to unjust care denials.
- The CMS stressed that any AI or algorithmic tool should aid in adherence to set coverage criteria without introducing biases or shifting standards.
- Insurers are warned against perpetuating discrimination through AI tools, with CMS increasing audit activities to enforce compliance.
- Coverage denials must now include detailed explanations, aligning with publicly posted, unchanging coverage criteria.
Source: AI cannot be used to deny health care coverage, feds clarify to insurers
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