US health insurance agency to use AI for authorising patient claims; how this may be a problem

The

Centers for Medicare and Medicaid Services

(CMS), a federal agency responsible for health insurance services in the US, has announced a new artificial intelligence (AI) based pilot program. A press release issued by the agency states that this AI-powered program will be used to assess the "appropriateness" of certain medical services. According to a report by The New York Times, the program is scheduled to begin in six states by 2026, which will apply prior authorisation to a group of Original Medicare recipients. According to a CMS press release, the AI algorithms will be used to ensure that care recipients are not receiving "wasteful, inappropriate services." The pilot program aims to target these services in Original Medicare, a process that is already common for those with Medicare Advantage.As per the report, similar AI-based algorithms like these have already faced litigation, adding that the AI companies involved “would have a strong financial incentive to deny claims.” The new pilot has even been described as an “AI death panels” program by the report.'

What the agency said about this AI-based program

In the press release, CMS wrote: “The Centers for Medicare & Medicaid Services (CMS) is announcing a new Innovation Center model aimed at helping ensure people with Original Medicare receive safe, effective, and necessary care.Through the Wasteful and Inappropriate Service Reduction (WISeR) Model, CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process relative to Original Medicare’s existing processes, helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars.The WISeR Model will test a new process on whether enhanced technologies, including artificial intelligence (AI), can expedite the prior authorization processes for select items and services that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use."