In 2024, significant changes have been introduced in the integration of AI (artificial intelligence) tools within the healthcare sector, particularly in the context of Medicare Advantage Insurance Plans. This update aims to provide clarity on the latest developments and their impact on healthcare coverage.

Introduction of AI in Healthcare: AI tools, such as Chat GPT, have gained widespread recognition among consumers globally. The healthcare industry has actively embraced AI technology across various medical domains, leveraging it to enhance diagnostic accuracy, gain additional insights, employ predictive modeling, and establish criteria for healthcare coverage.

Concerns from 2023: However, a noteworthy incident in 2023 revealed challenges in the use of AI tools. A major Medicare Advantage healthcare plan implemented an AI tool to determine the length-of-stay in care facilities for Medicare beneficiaries. Despite the physician deeming the stay medically necessary, the AI tool overrode this decision at an alarming rate of 90%. This resulted in patients being compelled to leave care facilities or face substantial out-of-pocket expenses, leading to financial and medical hardships.

Federal Regulations in Response: In response to such challenges, new federal regulations have been implemented for Medicare Advantage plans in 2024. These regulations aim to restrict the utilization of algorithms in making coverage decisions. Insurance companies employing AI tools are now mandated to ensure that determinations of medical necessity are based on the unique circumstances of each individual, rather than relying solely on algorithms that may not account for specific situations.

Key Regulatory Measures: AI tools must adhere to Medicare coverage criteria. Insurance plans are prohibited from denying benefits covered by original Medicare. Prior to denying coverage based on medical necessity, a comprehensive review by a physician or another relevant healthcare professional is mandatory.

Member Rights and Appeals: Importantly, every insurance member, including those covered by Medicare, Medicaid, or Commercial plans, retains the right to appeal a denial decision. This ensures that individuals have recourse in challenging decisions that may impact their coverage.

Take Home Points for 2024:

• Medicare Advantage Insurance Plans are subject to new AI regulations.

• AI algorithms will continue to be used, but individual circumstances must be considered.

• Denial of benefits covered by original Medicare is prohibited.

• Comprehensive physician review is required prior to denying coverage.

• Every insurance member has the right to appeal denial decisions.

In conclusion, the integration of AI in healthcare is evolving with a focus on balancing technological advancements with human intervention, reinforcing the importance of personalized and comprehensive healthcare decisions.

References https://www.reuters.com/legal/lawsuit-claims-unitedhealth-ai-wrongfully-denies-elderly-extended-care-2023-11-14/ https://www.medicaleconomics.com/view/unitedhealthcare-used-ai-to-deny-patients-health-insurance-coverage-lawsuit-says https://www.medscape.com/viewarticle/998653 https://www.cms.gov/files/document/cms-fy-2024-congressional-justification-estimates-appropriations-committees.pdf-0 https://www.cms.gov/files/document/2024-final-letter-issuers-508.pdf https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f