AI to Decide Medicare Coverage in New Pilot Program, Sparking Concerns Over Patient Care
Starting January, six states will pilot AI to assist Medicare prior authorization for select procedures. Providers worry AI may delay care and restrict necessary treatments.
AI to Be Tested in Medicare Prior Authorization Pilot Program
Starting January, six states including Oklahoma will pilot an artificial intelligence system to assist with prior authorization decisions in traditional Medicare. This program targets about a dozen procedures such as spine surgeries and steroid injections, where AI will help determine coverage eligibility.
Prior authorization has long been a point of friction for healthcare providers. Dr. Sumit Nanda, President of the Oklahoma State Medical Association, expressed concern that adding AI could exacerbate delays and restrict patient care. "Prior authorization restricts care," he said. "It often leads to delay in care, which then can lead to patient harm."
How the AI System Will Work
The government plans to contract private companies to run the AI evaluations. These companies will be financially incentivized to reduce unnecessary procedures by sharing in Medicare savings generated from denied claims. However, denials will still require review by licensed medical professionals to ensure appropriate oversight.
The director of the Center for Medicare and Medicaid Innovation explained the AI will focus on identifying expensive or potentially harmful practices. They can adjust the list of targeted procedures based on findings about overuse. Inappropriate decisions by AI or contractors may be penalized by the government to maintain accountability.
Balancing Cost Savings and Quality Care
Medicare administrator Dr. Mehmet Oz said the goal is to eliminate waste, fraud, and abuse while maintaining cost-effective care. Yet, providers remain wary. Dr. Nanda warns that cutting costs should not come at the expense of withholding necessary treatments. "We do not want to throw the baby out with the bathwater here," he noted.
The pilot program is expected to run for six years, offering valuable data on how AI can impact prior authorization processes. For insurance professionals, understanding these developments is critical as AI tools begin influencing claim approvals and cost controls.
To stay updated on AI applications in insurance and healthcare authorization, consider exploring courses on AI in insurance workflows and automation at Complete AI Training.
