AI Can’t Be Used To Deny You Health Coverage, Say Feds

In a memo sent to all Medicare Advantage insurers this week the Centers for Medicare & Medicaid Services (CMS) told health insurance companies that they can not use artificial intelligence or algorithms to determine a patient’s care or decide whether or not a procedure or individual is covered, Ars Technica reports.

The decision comes after several patients filed a lawsuit against Humana and United Healthcare claiming the group uses a flawed AI tool to deny care to patients that are on Medicare Advantage plans. Both plans use the same AI tool, a product called nH Predict that was developed by NaviHeath, a subsidiary of UnitedHeath.

According to the suit, the software often makes incorrect estimates of how long a patient needs to spend in places like nursing homes and rehabilitation centers after an incident like a stroke and then disciplines employees when a patient’s stay deviates from its estimates despite the fact that those estimates are often different than those made by a prescribing physician.

The new rules call out that scenario specifically:

“In an example involving a decision to terminate post-acute care services, an algorithm or software tool can be used to assist providers or MA plans in predicting a potential length of stay, but that prediction alone cannot be used as the basis to terminate post-acute care services.”

If a patient is denied coverage, that denial has to be based on coverage criteria that are publicly posted on a website that is not behind a password. If an insurer does ultimately deny coverage they also “must supply a specific and detailed explanation why services are either no longer reasonable and necessary or are no longer covered, including a description of the applicable coverage criteria and rules.”

In November of last year, members of the House of Representatives issued an open letter to the CMS specifically asking the agency to take a closer look at how AI and algorithms are used in determining coverage in the case of Medicare Advantage plans.

In the letter, the group said “Medicare Advantage plans are entrusted with providing medically necessary care to their enrollees. 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.”After years of working to get users to sign up, Google CEO Sundar Pichai announced that its subscription service Google One has officially surpassed 100 million subscribers.