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AI strikes again. The Algorithm Overlords deny healthcare. [1]

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Date: 2024-10-17  

I’m shocked I tell you to find out “...the three largest Medicare Advantage (MA) insurers are intentionally denying prior authorization requests for care in post-acute care facilities to boost profits.”

Rise Health summary of PSI report

“...United Healthcare, Humana, and CVS, who together cover nearly 60 percent of all MA enrollees” according to a new report conducted by the U.S. Senate Permanent Subcommittee on Investigations (a committee made famous by Joe McCarthy) that analyzed data that MA insurers are not required to make public, denied claims at an alarming rate. The PSI investigated and concluded with recommendations for CMS:

The Centers for Medicare & Medicaid Services (CMS) should collect prior authorization information by service category. Currently the way the agency collects data it is unclear whether insurers are using prior authorization to target particular types of care.

CMS should conduct targeted audits if insurer prior authorization data based on service category reveal a spike in adverse determination rates.

CMS should expand regulations for insurers’ utilization management committees to ensure that predictive technologies do not have undue influence on human reviewers. Even if predictive technologies are solely used to approve requests, nurses and doctors reviewing cases may face pressure to rubber-stamp the recommendations of algorithms and artificial intelligence, the committee said.

“Predictive Technologies” refer to the way “CVS used artificial intelligence in its post-acute analytics” to make decisions about coverage. Lots of juicy details in the summary of the report.

Enjoy!

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[1] Url: https://www.dailykos.com/story/2024/10/17/2277571/-AI-strikes-again-The-Algorithm-Overlords-deny-healthcare

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