CMS Limit Care restrictions for Patients by Restricting the Use of AI Predictive Health Software

The plot starts with predictive technology companies, whose software analyzes data to assist hospitals and insurance companies in choosing which policies to provide.

In order to match patients with comparable diagnoses and features, including age, pre-existing medical problems, and other criteria, patented "search engines" comb through millions of medical records. An algorithm predicts the type of care a particular patient will require and for how long based on these comparisons.

The tool frequently predicts a patient's date of discharge, which coincides with the date their insurer discontinues coverage, even if the patient requires additional treatment that the government-run Medicare would cover.

"There is a glaring mismatch" when an algorithm does not completely take into account a patient's demands, according to Rajeev Kumar, a doctor and the incoming president of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care professionals. "Human intervention is necessary in that situation."

Next year, when the Centers for Medicare and Medicaid Services will start limiting how Advantage plans utilize predictive technology tools to make some coverage choices, the federal government will attempt to level the playing field.

Private insurance companies administer Medicare Advantage programs, an alternative to the federally managed original Medicare program. Due to their reduced prices and improved features like dental care, hearing aids, and a variety of other things, about half of those eligible for full Medicare are enrolled in private plans.

The tools must still adhere to Medicare coverage requirements and cannot refuse benefits that are covered by original Medicare. If insurers believe the criteria are too broad, they can base algorithms on their own criteria, as long as the medical evidence supporting the algorithms is disclosed.

In addition, before refusing coverage deemed not medically essential, a coverage rejection "must be reviewed by a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the service at issue."

Because the guidelines do not specify precise consequences for infractions, David Lipschutz, associate director of the Center for Medicare Advocacy, is concerned about how CMS would enforce them.

Meena Seshamani, CMS's deputy administrator and director of the Medicare program, stated that the agency will conduct audits to ensure compliance with the new requirements and "will consider issuing an enforcement action, such as a civil money penalty or enrollment suspension, for the non-compliance."