It's ought to be against the law
BRETT WILKINS for Common Dreams
"In recent years, problems posed by prior authorization have been
exacerbated by MA plans' increasing use of AI or algorithmic software to assist
in their coverage determinations in certain care settings, including inpatient
hospitals, skilled nursing facilities, and home health," 32 House
Democrats led by Rep. Judy Chu (D-Calif.) wrote in a letter to Centers
for Medicare & Medicaid Services (CMS) Administrator Chiquita Books LaSure.
"Advocates and the media report that the use of such software has led to coverage decisions that are more restrictive than allowed under traditional Medicare rules, as well as more frequent and repeated denials of care," the lawmakers wrote.
"Absent prohibiting the use of AI/algorithmic tools
outright, it is unclear how CMS is monitoring and evaluating MA plans' use of
such tools in order ensure that plans comply with Medicare's rules and do not
inappropriately create barriers to care."
The lawmakers are calling on CMS to take steps including, but not limited
to:
- Requiring MA plans to report prior authorization data including reason for denial, by type of service, beneficiary characteristics (such as health conditions), and timeliness of prior authorization decisions;
- Comparing "guidance" generated by AI and algorithmic tools with actual MA coverage decisions;
- Assessing how and to what extent initial prior-authorized AI determinations for services are adjusted to account for unanticipated changes in a patients' condition;
- Requiring attestation from MA plans and contractors that their coverage guidelines are not more restrictive than traditional Medicare; and
- Determining whether MA plans are inappropriately using race/other factors in these algorithms.
MA plans are not part of Medicare. They are a private health insurance
"scam" created by a GOP-controlled Congress and signed into law 20
years ago by then-President George W. Bush "as a way of routing hundreds
of billions of taxpayer dollars into the pockets of for-profit insurance
companies," according to frequent Common
Dreams opinion contributor Thom Hartmann.
A report published last
month by Physicians for a National Health Program revealed that MA plans are
overcharging U.S. taxpayers by up to $140 billion per year, enough to
completely eliminate Medicare Part B premiums or fully fund Medicare's
prescription drug program.
The lawmakers' letter is endorsed by advocacy groups including the Center for Medicare Advocacy, Public Citizen, Social Security Works, Center for Health and Democracy, and Business Leaders for Health Care Transformation.
"The use of AI by Medicare Advantage insurers to deny needed care to
seniors and people with disabilities represents the most recent and dangerous
step by greedy companies focused on profit instead of patients," Public
Citizen executive vice president Lisa Gilbert said in a statement.
"Now is the time for CMS to crack down on companies that are using AI
and other mechanisms to deny care that would be covered if the enrollee were
covered by traditional Medicare," Gilbert added. "Understanding how
Medicare Advantage insurers are using AI to deny needed care and holding bad
actors accountable are crucial steps to protecting seniors and the Medicare
program."
Last year, a U.S. Senate probe found that
insurance companies and other brokers are "running amok" with
"fraudsters and scam artists" making false or misleading claims to
dupe senior citizens into purchasing MA plans.
Progressive lawmakers have also criticized President
Joe Biden for delaying promised curbs on Medicare Advantage plans amid heavy
insurance industry lobbying.
Earlier this year, Reps. Mark
Pocan (D-Wis.)—one of the 32 lawmakers who signed the letter to
Brooks LaSure—Ro Khanna (D-Calif.), and Jan Schakowsky reintroduced a bill
to change the official name of MA to "alternative private health
plan" to make clear that such coverage is offered by for-profit companies.
"The scheme is called Medicare Advantage," Pocan and
Khanna explained. "But in
reality, so-called 'Medicare Advantage' is neither Medicare nor an
advantage."
