Medicare Advantage Opens “AI Can of Worms” for Patients

Medicare Advantage’s use of artificial intelligence (AI) to deny needed health care to seniors and people with disabilities raises red flags that regulators must continue to address, said Public Citizen today in response to a letter sent by members of Congress to Centers for Medicare & Medicaid Services (CMS) urging action.

“Medicare Advantage opens an AI can of worms for patients that will be hard to address without stringent regulations,” said Eagan Kemp, health care policy advocate at Public Citizen. “We applaud the members of Congress who are demanding oversight of this technology that is being used and abused to buttress profits through privatized Medicare Advantage plans.”

In a letter spearheaded by Rep. Judy Chu (D-Calif.), Rep. Jerrold Nadler (D-NY), and Sen. Elizabeth Warren (D-Mass.) more than 50 members of Congress expressed concerns about privatized Medicare plans’ use of artificial intelligence (AI) and algorithmic software in prior authorization to guide coverage decisions. “Plans continue to use AI tools to erroneously deny care and contradict provider assessment findings,” noted the letter. “We believe more detailed guidance is needed to protect access to care for Medicare beneficiaries and improve clarity for providers.”

The letter urges CMS to clarify the specific elements that must be contained in prior authorization denial notices and establish an approval process to review AI and algorithmic tools, among other guardrails concerning the use of the technology.

In response to the Biden administration’s Executive Action on Artificial Intelligence (AI), which included a number of directives for agencies dealing with health care, earlier this year Public Citizen urged the U.S. Department of Health and Human Services to ensure that AI is robustly regulated in order to put patients before profits.