SUBSCRIBE TO OUR FREE NEWSLETTER
Daily news & progressive opinion—funded by the people, not the corporations—delivered straight to your inbox.
5
#000000
#FFFFFF
5
#000000
#FFFFFF
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.
Jun 25, 2024
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 Vermontwrote 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.
An Urgent Message From Our Co-Founder
Dear Common Dreams reader, It’s been nearly 30 years since I co-founded Common Dreams with my late wife, Lina Newhouser. We had the radical notion that journalism should serve the public good, not corporate profits. It was clear to us from the outset what it would take to build such a project. No paid advertisements. No corporate sponsors. No millionaire publisher telling us what to think or do. Many people said we wouldn't last a year, but we proved those doubters wrong. Together with a tremendous team of journalists and dedicated staff, we built an independent media outlet free from the constraints of profits and corporate control. Our mission has always been simple: To inform. To inspire. To ignite change for the common good. Building Common Dreams was not easy. Our survival was never guaranteed. When you take on the most powerful forces—Wall Street greed, fossil fuel industry destruction, Big Tech lobbyists, and uber-rich oligarchs who have spent billions upon billions rigging the economy and democracy in their favor—the only bulwark you have is supporters who believe in your work. But here’s the urgent message from me today. It's never been this bad out there. And it's never been this hard to keep us going. At the very moment Common Dreams is most needed, the threats we face are intensifying. We need your support now more than ever. We don't accept corporate advertising and never will. We don't have a paywall because we don't think people should be blocked from critical news based on their ability to pay. Everything we do is funded by the donations of readers like you. When everyone does the little they can afford, we are strong. But if that support retreats or dries up, so do we. Will you donate now to make sure Common Dreams not only survives but thrives? —Craig Brown, Co-founder |
Our work is licensed under Creative Commons (CC BY-NC-ND 3.0). Feel free to republish and share widely.
thom hartmannmedicareunitedhealth groupmedicare advantageseniorspublic citizenartificial intelligencecenters for medicare and medicaid serviceshealthcare
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 Vermontwrote 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.
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 Vermontwrote 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.
We've had enough. The 1% own and operate the corporate media. They are doing everything they can to defend the status quo, squash dissent and protect the wealthy and the powerful. The Common Dreams media model is different. We cover the news that matters to the 99%. Our mission? To inform. To inspire. To ignite change for the common good. How? Nonprofit. Independent. Reader-supported. Free to read. Free to republish. Free to share. With no advertising. No paywalls. No selling of your data. Thousands of small donations fund our newsroom and allow us to continue publishing. Can you chip in? We can't do it without you. Thank you.