CMS, Senate Seek to Crack Down on Insurer Use of AI

In a recent memo, the Biden administration clarified restrictions on the use of artificial intelligence in Medicare Advantage coverage decisions. Congress may also eventually weigh in on AI use in federal health insurance programs: The Senate Finance Committee on Feb. 8 held a hearing in which senators indicated they may tighten the rules on payer and provider use of AI, particularly in Medicare and Medicaid. 

In its Feb. 6 memo, CMS sought to address questions it received after finalizing a rule last April that made technical changes to the MA program. The frequently asked questions (FAQ) document confirmed that “an algorithm or software tool can be used to assist MA plans in making coverage determinations,” but it also emphasized that plans must base coverage decisions “on the individual patient’s circumstances.” According to one D.C. insider, the rule may force plans to move faster to curb misuse of AI and algorithms in decision making.