CMS directive highlights the need for transparency and accountability in AI and algorithmic usage in coverage determinations, responding to concerns raised by House of Representatives members regarding Medicare Advantage plans.
The Centers for Medicare & Medicaid Services (CMS) has issued a pivotal
directive
to
medical insurance
companies. As a part of the new directive,
CMS
has forbidden the use of artificial intelligence (
AI
) or algorithms in crucial decisions about
patient care
or coverage eligibility.
What went wrong and why CMS has issued with directive
This new directive has been issued by CMS after a legal action initiated by several patients against Humana and United Healthcare regarding the use of a flawed AI tool -- nH Predict, developed by NaviHealth, a subsidiary of UnitedHealth
The lawsuit contends that the nH Predict software frequently generates inaccurate estimates for the duration of patient stays in facilities like nursing homes and rehabilitation centres following events such as strokes.
Moreover, it alleges punitive measures against healthcare providers when a patient's stay diverges from the software's estimates, despite disparities with assessments made by prescribing physicians.
How CMS’s new regulations affect insurance providers
The newly established regulations specifically address this issue, asserting that while algorithms or software tools can aid in predicting potential lengths of stay, these predictions alone cannot serve as the sole basis for terminating post-acute care services.
In addition, CMS mandates transparency by stipulating that if coverage is denied, the denial must be grounded in publicly accessible coverage criteria, excluding password protection.
Furthermore, insurers are obliged to provide a comprehensive explanation for deeming services no longer reasonable and necessary, including a thorough description of applicable coverage criteria and rules.
This development gains significance in the context of an open letter from House of Representatives members to CMS in November, urging a meticulous examination of AI and algorithmic usage in coverage determinations, particularly within Medicare Advantage plans.
The recent CMS directive emphasises the imperative need for transparency and accountability in integrating AI tools within the healthcare system, marking a pivotal step toward ensuring fairness and accuracy in patient care decisions.
English (US) ·