Advocates hold signs during a news conference on Medicare Advantage plans

Advocates hold signs during a news conference on Medicare Advantage plans in front of the U.S. Capitol in Washington, D.C. on July 25, 2023.

(Photo: Alex Wong/Getty Images)

Alarms Raised Over For-Profit Medicare Advantage Using AI to Deny Care to Seniors

"Insurers using AI to deny needed care to seniors and people with disabilities means sacrificing patient needs on the altar of corporate greed," said one campaigner.

Dozens of Democratic U.S. lawmakers joined consumer and patient advocates on Tuesday in sounding the alarm over the use of artificial intelligence by companies providing Medicare Advantage plans to deny healthcare to their senior customers.

Fifty-one Democratic members of Congress and Independent Sen. Bernie Sanders of Vermont wrote to Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Books LaSure on Tuesday expressing their concern over Medicare Advantage (MA) providers' increasing use of algorithmic systems to deny patient care.

"Plans continue to use AI tool to erroneously deny care and contradict provider assessment findings," the letter notes. "Last year, a class action lawsuit was filed alleging that UnitedHealth Group unlawfully used an AI algorithm, nH Predict, to deny rehabilitative care to sick Medicare Advantage patients."

"The lawsuit cites an investigation suggesting that UnitedHealth Group pressured employees to use the algorithm to issue payment denials to Medicare Advantage beneficiaries and set a goal for employees to keep patient rehabilitation stays within 1% of the length of stay predicted by nH Predict," the lawmakers continued.

MA plans are not part of Medicare. They are a private health insurance "scam" created by a Republican-controlled Congress and signed into law by then-President George W. Bush "as a way of routing hundreds of billions of taxpayer dollars into the pockets of for-profit insurance companies," according to frequent Common Dreams opinion contributor Thom Hartmann.

Advocates have warned about the use of AI in MA denials since at least last year, while imploring congressional and regulator action to protect seniors and people with disabilities from being preyed upon by what critics have called "Medicare disadvantage" companies.

In February, CMS "clarified that Medicare Advantage organizations may use algorithms, artificial intelligence, and related technologies to assist in making coverage determinations, but these technologies may not override standards related to medical necessity and other applicable rules for how coverage determinations by Medicare Advantage organizations are made."

Rights groups echoed the lawmakers' concerns about the use of AI for MA denials.

"Medicare Advantage insurers using AI to deny needed care to seniors and people with disabilities means sacrificing patient needs on the altar of corporate greed," Public Citizen executive vice president Lisa Gilbert said. "CMS must expand upon the steps it has already taken to improve oversight of companies using AI to deny care that would be covered by traditional Medicare."

"It is time to protect enrollees by cracking down on Medicare Advantage insurers using AI to deny needed care through additional reporting requirements and increased enforcement actions against bad actors," Gilbert added.

David Lipschutz, associate director of the Center for Medicare Advocacy, said in a statement that "in our experience, MA plans' use of AI or algorithmic software has led to more inappropriate denials and premature terminations of care—this must end."

A report published earlier this month revealed that MA plans have overcharged the federal government by $612 billion since 2007—and $82 billion last year alone. Another report published last year by Physicians for a National Health Program found that MA plans are also overcharging U.S. taxpayers by up to $140 billion per year, enough to erase all Medicare Part B premiums or fully fund Medicare's prescription drug program.

A 2022 U.S. Senate Finance Committee investigation found that insurance companies and other brokers are "running amok" with "fraudsters and scam artists" making false or misleading claims to dupe seniors into buying MA plans. In February 2023, Reps. Mark Pocan (D-Wis.), Ro Khanna (D-Calif.), and Jan Schakowsky (D-Ill.) reintroduced legislation to change the official name of MA to "alternative private health plan" to make clear that such coverage is offered by for-profit companies.

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