AI cannot be used to deny health care coverage, feds clarify to insurers

Key Points:

  • Health insurance companies cannot use algorithms or artificial intelligence to determine care or deny coverage to members on Medicare Advantage plans
  • Insurers must base coverage decisions on individual patient’s circumstances, not just a larger data set
  • AI tools can only be used by insurers as a check to ensure fidelity with coverage criteria

Summary:

CMS decreed that health insurance companies can’t use AI tools to determine Medical Advantage coverage decisions for Medicare Advantage plans. nH Predict, an AI solution developed by NaviHealth and embraced by the likes of UnitedHealth and Humana, is accused of generating doomsday predictions about post-acute care that don’t quite align with medical reality. The CMS has declared that AI tools can’t be the judge, jury, and executioner when it comes to coverage decisions. The CMS demands a personal touch, managing individual patient circumstances before determining coverage.

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